AMINU SALEH COLLEGE OF EDUCATION AZARE

SCHOOL OF UNDERGRADUATE STUDIES

COURSE CODE:-HED 206:

COURSE LECTURER: YUSUF AMINU (RN, DPA, M. Ed, HEALTH)

LECTURE NOTE, JANUARY 2018.

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The understanding of what food is has become so fundamental to the understanding of
nutrition, as many members of the health team often misrepresent it. Scientifically however,
food is any substance (solid or liquid) which when ingested provides the necessary raw
materials for the structure and functions of life, thus enabling the body to carry out its life’s
function. Food is an edible substance that human being or animals eat or drinks that supply
all the nutrients that will sustain maintain and promote life and growth. For example beans,
maize, milk, fruit.
If man must succeed in his quest to overcome the problem of hunger, he should start by
taking a retrospective view of his past as a guide for the future. An author once remarked,
"What little we know, what little power we possess, we owe to the accumulated
endeavours of our ancestors."
The oldest human records indicate that there was an awareness of the relationship between
what we eat and what we are - and that food supplies the energy of life, becomes a part of us
as well as change us. Indeed, it takes little science to learn that we feel good when we eat and
bad when we go hungry. Man also learnt early to know that those who have plenty of food
are likely to have fewer episodes of sickness. Furthermore, man learnt which foods can be
consumed and which ones are poisonous. For example, our local people know which
mushrooms can be eaten, and which ones are not to be eaten. However, if one knows that
certain potato tuber is safe and nourishing, he might not be able to tell if the potato leaves are
poisonous. Thus, such knowledge is valuable for human existence, but it may not provide the
basic understanding of how foods function.
Some Basic Nutritional Terminologies
Nutrients: are chemical components of food that supply nourishment to the body. Examples
are protein, fats, vitamins, minerals, water and carbohydrates.
Micronutrients: are the very small molecules that are also part of food composition that are
needed in small quantities in the body but very important for food health. Examples of
micronutrients are iodine, zinc, iron, vitamin A, selenium and others.
Adequate diet: is a diet that contains all the essential nutrients taking in the right proportion
at a sitting. In our own community, an adequate diet is ‘one that contains at least one food
item from all the food groups e.g. carbohydrate, protein, fat and oil, etc.
Malnutrition: simply means bad nutrition. Bad nutrition can be classified as under or over
nutrition.
Food value: refers to the quality and quantity of essential nutrients that each food contains
that will promote and rehabilitate good health.
Food security: is defined as the availability of food-stuffs in enough quantity and quality to
every member of the household regardless of age, sex, religion, and individual condition.
Nutrition security: is the utilisation of the food nutrients in the body system in order to
restore, maintain and promote quality and healthful life.
What is nutrition?
The most acceptable definition of nutrition is the one given by Robinson at the Congress of
the American Medical Association in 1966 as the branch of science which deals with food,
the nutrients and other substances therein; their action, interaction and balance the processes
by which an organism ingests, digests, absorbs, transports, utilizes and excretes food
substances in relation to health and disease.

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It has also been observed that “nutrition must also be concerned with the social, economic,
cultural and psychological” factors relating to food consumption, food production and
distribution. However, for an individual, nutrition represents an accumulation of the eating
habits formed throughout a life-time. They vary from individual to individual and from one
culture and geographical environment to another. Thus, they are molded by the availability of
food, food preferences and culture. In this text, nutrition may be defined simply as "the
science that interprets the relationship of food to the functioning living organism."
What is health?
The WHO has defined health as "a state of complete physical, mental and social wellbeing
and not merely the absence of disease or infirmity.” On account of the fact that this WHO
definition is virtually unattainable in a real world, the definition of health today is turning
towards the idea of an optimum state of living effectiveness. Thus, we have another definition
of health which, in measurable terms, is a state characterized by anatomic integrity, ability to
perform personal valued family, work and community roles; ability to deal with physical,
biologic and social stress; a feeling of well-being; and freedom from risk of disease and
untimely death. It is a state of equilibrium between humans and the physical, biologic and
social environment, compatible with full functional activity. Thus, in the language of
nutrition, the attributes of an optimally healthy (well-nourished) individual are predicated on
correct eating-habits which result in a well-built body (right weight and height for age,
barring the hereditary traits), which is energetic, good-natured and mentally alert. Such
individuals have clear skin, good eye-sight, and a head with plenty of hairs and a good
appetite.
What is a disease?
A disease can be defined as an interruption, cessation or disorder of body functions, systems,
or organs. Nutritional disease is a state of health which arises from the deficiency
(inadequacy), an excess or an imbalance of the supplies of nutrients and/or calories. It can be
classified into two namely primary and secondary diseases. For example, a disease which
directly results from a lack of a certain nutrient is called a deficiency disease, e.g. beriberi,
which is due to the lack of thiamin (vitamin B 1). This differs from malnutrition in that in the
malnourished state, the expression of a disease condition may or may not become as obvious
as in the disease state. Simply, malnutrition means bad nutrition. The nutritional diseases
commonly encountered include Beriberi, Pellagra, goiter, Ariboflavinosis, Dental caries,
rickets/Osteomalacia, Kwashiorkor, Marasmus/Starvation, Nutritional Anaemias,
Xerophthalmia/keratomalacia and obesity.
What are nutrients?
Nutrients are chemical constituents of food which must be supplied to the body in suitable
amounts. They include the carbohydrates, fats/oils, proteins, vitamins, minerals and
water. Carbohydrates, fats, proteins and water can be referred to as macro-nutrients since
they are required in relatively large amounts. However, only carbohydrates, fats and proteins
can provide energy. Proteins are chiefly responsible for growth, tissue repair and
maintenance, while the vitamins and minerals mainly help to regulate chemical processes in
the body. Water affords the body a means of transportation of most substances to and from
the cells and for all cellular activities. In summary, nutrients can be said to function in three
major ways: firstly, by providing the body with fuel for the release of energy; secondly, by

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providing the building materials for growth and upkeep of the body; and thirdly, by providing
the materials necessary for the regulation of body processes, so that the body can use these to
synthesize its own regulatory substances. On this basis, the above-named nutrients can be
divided into three groups:
a) Energy-giving nutrients, which are the proteins, the fats and oils and the
carbohydrates;
b) The body-building nutrients, which include the proteins, fats, carbohydrates, minerals
and water; and
c) The body processes regulatory substances; include proteins, minerals, vitamins and
water only.
What is food?
Food has generally been equated with body fuel since the time of the primitive man; and fuel
was understood to be that which is burnt by the body to produce heat or power. Even today,
the lay Nigerian makes reference to food in terms of its caloric content. In Nigeria, meals are
named by its most preponderant carbohydrate content. For example, an American would eat
‘beef’, ‘lamb’, ‘pork’ ‘chicken’, ‘turkey’ or ‘fish’ for lunch, while his Nigerian counterpart
would tell you that he eats rice, amala, eba. In this case, the protein-rich foods in the meal are
not emphasized. Food is any substance (solid or liquid) which when ingested provides the
necessary raw materials for the structure and functions of life, thus enabling the body to
carry out its life's functions.
The Functions of food
1. The primary function of food is to supply energy to the body. The first body
requirement is to have enough energy before performing other functions. The energy
nutrients include carbohydrates, fats and proteins. The food source of energy is
carbohydrate, fats and oils.
2. Food nutrients also build and maintain body tissues. The body building material in
food is protein.
3. Food nutrients also regulate body processes. The minerals, the vitamins and water
each of these nutrients present in the food you consume perform certain regulatory
functions that are crucial to the normal operation of the body system. Such regulations
include the movement of fluids, the coagulation of blood, maintenance of normal
body temperature and control of the balance between acid and base.
4. Food serves as a socializing agent or as means of friendship.
5. It also serves as means of developing social rapport.
6. Food is also a way of satisfying certain emotional needs.
7. Food is also used as a means of expressing feelings. The serving of favorite foods and
its withdrawal is an expression of appreciation of punishment respectively.
Basic foods Groups
This is means by which foods are grouped according to their similarities. The
grouping of foods in most health institutions in many parts of Africa, especially
Nigeria, is based on the function(s) of the most preponderant component of such
foods. Thus, foods are classified as “energy foods”, “body-building foods”,
“protecting foods” or “accessory food substances” very much in line with the earliest
food classifications. This classification is obviously obsolete, inappropriate or even

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 misleading in the light of our improved knowledge and understanding of foods and
nutrition, for practically all common foods offer at least two or more nutrients see
table below, and thus, each foodstuff contributes substantially to the overall
nutritional balance of the individual. The value of any food depends on its nutrient
content that is directly responsible for the value or functions assigned to it. In a
community where the consumer’s knowledge of nutrition and food and the resources
for making a wise choice of the latter is rather limited, it is instructive to set out
guidelines which can aid the consumer make these choices in order to meet the known
nutritional needs. It is on the basis of these considerations that foods are classified. On
the basis of the above-mentioned rationale for grouping foods, the following four food
groups are widely recognized around the world.
FOOD GROUPS NUTRIENTS
Milk group Phosphorus, Calcium, Vit A, amino acids Vit
B1 and 2
Meat Group Amino acids, Iron, Vit B and Phosphorus
Fish, Eggs poultry, beans, meat
Cereal Starchy/Tuber Group Vitamin B complex, iron carbohydrates and
Wheat, rice, barley, oats, white bread, brown cellulose
rice maze or corn, white beans, kidney beans,
pinto beans and lima beans
Fruit/Vegetable group Calcium, mineral, Vit C. and B, cellulose.
Eggplant, cucumber, lettuce and squase,
carrot, potato, onion, oranges, mango,
pineapple, apple, blackberries, blueberries,
plums, tangerine, grapes, pawpaw, banana
The Food Groups
The following five food groups are widely recognized around the world:
i. Milk Group: It is from this group that the human infant gets its first taste of a human
diet. The group is made up of all dairy products including fresh milk, skim milk,
condensed milk, powdered milk, local and foreign cheeses, butter, yogurt and ice cream.
Individuals with varying degrees of lactose intolerance have a choice of cheeses, butter
milk, butter and yogurt. However, for those who must watch their weights, the use of ice
cream and other milk-containing beverages should be restricted. However, this group is
especially valued for its content of calcium, magnesium, riboflavin, cobalamin and
proteins of high quality. But it is notably low in iron and ascorbic acid.
ii. "Meat" Group: This group includes such diverse food items as meats, poultry, eggs,
fish, snails, shrimps, crabs and other sea foods; termites and other edible insects such as
caterpillar, locusts, crickets and grass-hoppers; legumes (pulses), seeds and nuts.
iii. Cereal Group: The cereal grains belong to the family of grasses and they include
maize, guinea corn (sorghum), wheat, rice, barley, oats and teff. But the latter three are
not popular in Nigeria.
iv. Starchy Fruit/Tuber Group: The members of this group include yams, coco-yams,
cassava, potato, sweet potato, plantain and bread-fruit. These food crops are usually easily
cultivated and are the staples in the wetter, more humid regions of Nigeria. They contain

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 large quantities of starch and are therefore fairly easily obtainable sources of food energy.
v. Fruit/Vegetable Group: The term ‘vegetable' is used to include some fruits (e.g.
tomatoes and pumpkins), leaves (e.g. spinach and cabbage), roots (e.g. carrots), and even
stalks (e.g. celery), and flowers (e.g. cauliflower). A wide variety of fruits grows wild or
is cultivated. The contribution of this group of foods is the provision of nutritionally
important quantities of water-soluble vitamins, especially folic acid and ascorbic acid,
carotene (the pre-cursor of vitamin A), and minerals. Furthermore, many members of this
group make substantial contribution of roughage to the diet in the form of cellulose. But
the fruit members have low protein content which, though often ignored, may not be
negligible.
Classes of Food
The classification of foods is essential to the study of nutrition because by grouping together
foods with similar nutrient content, it is possible to choose from a wide variety of alternatives
if certain foods become scarce or money is in short supply. It includes choices that permit
flexibility for seasonal, regional and budgetary considerations. Throughout the world, food
groupings are used to translate nutritional needs into practical guidelines for food intake.
These groupings are usually determined first and foremost, by their nutrient content. Thus,
foods are grouped according to their similarity of nutrient content. A food that has a high
nutrient density is one that has a high proportion of nutrients to the amount of calories
supplied.
Carbohydrates
There are two types of carbohydrates. They are simple and complex carbohydrates. Simple
carbohydrates are;
a) Monosaccharides.
b) Disaccharides
The most important monosaccharide is glucose. Glucose is needed every second by the brain.
The disaccharides are two molecules of sugar, such as sucrose, maltose and lactose. Sucrose
is broken down to fructose and glucose, while maltose is broken down to two molecules of
glucose. Lactose is popularly referred to milk sugar. Upon digestion it yields glucose and
galactose. Galactose, fructose and fructose are examples of monosaccharide. Complex
carbohydrates are polysaccharides that contain as many as 2000 simple carbohydrates units in
long chains. Starch, glycogen, and cellulose are examples of complex carbohydrates. Starch
is found in seeds, and grains and tubers. Glycogen is a form of glucose storage in animals.
The major carbohydrates are found in sugars, cereal (corn, millet, wheat, rice, guinea corn,
acha), legumes (beans, soya beans, groundnut and dried fruits, tubers and vegetable).
Functions of carbohydrates
i. It supplies energy which serves as body fuel to both internal and external
activities.
ii. It spares protein from being used as a source of energy. One gram of carbohydrate
will supply 4 kilocalories to the body.
iii. It supplies glucose to the body especially the brain
iv. It helps the body to burn body fat.
v. It adds flavor to our diet.

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 vi. It helps in the formation of genetic materials (Deoxyribonucleic DNA and
Ribonucleic acid RNA).
Digestion of carbohydrates
Digestion of carbohydrates begins in the mouth and ends in the small intestine. In the mouth,
the food is chewed and broken down into small pieces and moistens and mixed with saliva
which contains salivary amylase ptyalin. This enzyme splits un-branched chain
polysaccharides into small branched chain polysaccharides and disaccharides such as
maltose. In the stomach the hydrochloric acid will inactivate the salivary enzymes, ptyalin.
The digestion continues in the duodenum (the first part of the small intestine) that contains
pancreatic amylase which continues to break down other polysaccharides to disaccharides.
The other enzymes in the intestine are maltase, sucrose and lactase. Maltase breaks down
maltose into two molecules of glucose, the final end product which is glucose. Lactase breaks
down lactose into one molecule each of glucose and galactose and sucrose converts sucrose
into one molecule each of glucose and fructose. Remember that the end product of
carbohydrate is glucose.
Protein
The word “protein” simply means, to come first. This nutrient is the most indispensable
nutrient that supplies essential and non-essential amino acids. These essential amino acids are
necessary for body building and tissue repairmen. Protein can be simple grouped under two
broad headings. The animal and plant protein sources, animal protein sources are usually
referred to as complete protein because it contains all the essential amino acids while plant
sources are regarded as incomplete protein b they mostly lack some essential amino acids.
Essential amino acids these are the amino acids that body cannot synthesize in amounts
sufficient to meet the physiological needs they must be provided in a diet, these are
(Isoleucine), Leucine, Lysine, Methionine, Phenylalanine, Threonine, Tryptophan, and
Valine). These eight essential amino acids are for adults. For infants, Histidine is listed as 9 th
amino acid essential for them. Proteins are majorly classified according to their solubility’s
and other physical properties. The non-essential amino acids are Alarnine, Arginine,
Asparagines, Aspartic Acid, Cystein, Glutanic acid, Glutamines, Glycine, Proline, Selin and
Tyrosine. Proteins are majorly classified according to their solubility and other physical
properties. Three classes are used to categorize protein:
 Simple proteins; - these are protein substances that yield amino acids after
complete hydrolysis. Albumen of egg, keratin of hair and globin of haemoglobin are
examples of simple proteins.
 Conjugal proteins: these are protein compounds with some other non-protein
molecules or molecules with metal upon hydrolysis. Examples are haemoglobin
(protein + heine) of blood, casein (protein + phosphoric acid of milk and lipoprotein
(protein + lipid) in blood plasma.
 Derived proteins: - these are products formed from the partial breakdown of
proteins by the action of heat and other physical forces or by hydrolytic agents,
peptones, polypeptides, and peptides, (mixtures of amino acids with decreasing
numbers of amino acids in the chains length).

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There are two types of protein supplementary and complementary protein. All animal
proteins are first class protein because they contain all the essential amino acids. Plant
proteins on the other hand are regarded as second class protein because they lack one or two
essential amino acids. When you add an animal protein to a protein from plant source, such a
combination is regarded as supplementary protein. For example, maize + meat, groundnut +
crayfish etc. it is the animal protein that is supplying all the essential amino acids.
Complementary proteins are the combinations of two important plant protein sources.
Examples are beans and rice, maize and groundnut. Grains are deficient in lysine and
legumes are deficient in methionine. Rice, millet maize and wheat are grains while beans and
groundnut are legumes. The food sources of animal proteins include fish, crayfish, eggs,
milk, goat, meat, pork, chicken, turkey crab, breast milk etc. the major plant protein sources
are cowpea seeds, soybeans, groundnuts, locust beans, pinto beans, red kidney beans and lima
beans. Grains such as rice, wheat, maize, guinea corn, acha, millet are also fair sources of
protein.
Functions of protein
The chief functions of protein are to:
1. Provide amino acids for the body to build new tissues, and normal growth of infants.
2. Help to maintain body tissue and replacement of damaged or worn out tissues in both
adults and children.
3. Help in the formation of hormones, enzymes and antibodies.
4. Transporting substances around the body
5. Serve as source of energy in the absence of carbohydrate.
Digestion of protein
Protein digestion starts from the stomach. The long chains of proteins are split into smaller
units by an inactive enzyme pepsinogen that is converted to pepsin upon being in contact
with hydrochloric acid. The main protein connective tissue, called collagen is digested by
pepsin. The vast majority of protein digestion occurs in the duodenum. The liquefied mass of
food called chime passes through the pyloric sphincter into small intestine where the
activation of enterokinase, an enzyme that activates pancreatic trypsinogen into trypsin.
Trypsin, chymotrypsin and dipeptides. These result in free amino acids. A deficiency disease
of protein is called Protein Energy Malnutrition (PEM). It is used to be known as Protein
Caloric Malnutrition (PCM). The term energy refers to both caloric and fats. The patterns of
PEM are, kwashiorkor, Marasmus, Marasmic – Kwashiorkor and under nutrition. Other form
of protein deficiency in humans includes nutritional liver disease. This deficiency is
commonly observed in alcoholic patient and kwashiorkor children. The disease is
characterized by an enlarged fatty liver and oederma.
Lipids
The term lipid is descriptive rather than a chemical name such as carbohydrates or protein.
The term refers to fats like substances. Lipids are classifies into two groups, simple and
compound lipids. Simple lipids are the esters of fatty acids and alcohol. Examples of ester of
fatty acids include animal and vegetable fats. Compound lipids are esters of fatty acids
containing groups in addition to an alcohol and a fatty acid. Examples of these lipids include
phospholipids such as Lecithin found in egg yolk and milk sterol, such as cholesterol.

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Doubles that protein and carbohydrate. One gram of carbohydrates and protein will yield 4
kcal, each but fats will yield 9kcal.
Fats are available in liquid and solid forms. Fluid fats, such as groundnuts oil and palm oil are
primarily unsaturated, while the solid fats such as butter and meat-fat are saturated. The term
saturated or unsaturated are used to described more desirable than saturated fatty acids
because they contain fatty acids label essential. The term ‘essential’ or ‘non-essential’ when
applied to fatty acids refer to two fold physiologic fats:
 Fatty acid is essential if its absence will create specific deficiency disease
 Fatty acid is essential if the body is unable to manufacture it, therefore must be
obtained from diet.
Fatty acids can be described as the building blocks of lipids (fats and oils). Like proteins and
carbohydrates, they are made up of hydrogen carbon (CH) but they differ by having a
carboxyl group (COOH) at the end. Animal fats contain more of saturated fatty acids. This is
one of the reasons for animal fats to be solids at room temperature because they contain
unsaturated fatty acids. This means some of the carbons are not filled. Some of these
unsaturated fatty acids are essential to humans because the body system cannot provide them
enough to meet body requirements are Linolenic, Linoleic and arachidonic acids. Rich
sources of oils are available in plants, such as corn oil, groundnut oil, melon oil, soybean oil
and palm oil. Pam oil contains a lot of palmitic acid which is made up of saturated fatty acids.
Rich sources of fats are mainly from animal food sources such as pork, meat whole milk and
cheese.
Functions of Fats
a. Strengthening capillary and cell-membranes structures
b. One of the chief functions of fats is to supply energy.
c. Prolonging blood clothing zinc
d. Fat helps the body to transport fat soluble vitamins (A, D E and K).
e. Lowering seven cholesterol
f. Lubricating the digestive tract and slows down digestion
g. Fat helps in protecting the internal organs of the body by serving as cushion pad, for
example the kidney.
h. Oils provides the essential fatty acids which help in preventing excessive loss of water
i. Fat gives taste and feeling of satisfaction in a meal. Without fats food will be too dry
to eat.
j. Dietary fat stored as adipose tissue sin man helps man to survive without food for
some weeks.
k. Fat is used by food manufacturers for smoothness and tenderness.
Digestion of Fats
The digestion of fats begin in the mouth lingual lipase act upon lipids, upon reaching stomach
gastric lipase is also being released to further break it into shorter triglyceride; diglycerides
and fatty acids. In the small intestine, the fats are also split into simpler units by the bile
which is being released by gallbladder and the pancreatic lipase by pancrease. It is the bile
fluid, the bile salts serves as emulsifying agent. These bile salts also accelerate the pancreatic
lipase (enzyme that breaks fats) and it also neutralizes the acidity of the chime. The end
products of lipids digestion are fatty acids, glycerol and glycerides.

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Minerals
Generally, minerals are inorganic elements, organic compounds; they cannot be changed
during digestion. Once they are in the body, they are there until they are excreted. Minerals
can be classified into two classes, macro and micros minerals: The macro minerals are those
that the body needs in larger amounts than 5 grams (a teaspoon). These macro or major
minerals include calcium, phosphorus, potassium, sulfur, sodium, chloride and magnesium.
Calcium and phosphorus are the two major minerals needed by the body in the highest
quantities less than 5 grams. These micro minerals are iron, zinc, copper, h, iodine, selenium.
There are other nine trace minerals. These are cobalt, molybdenum, chromium, tin,
vanadium, fluorine, silicon, nickel, and arsenic.
Functions of minerals
Majority, minerals function in two important roles as building and regulatory substances.
Specifically, the functions of minerals are:
1. They are building parts in the hard tissues of the body (bones and teeth).
2. They give rigidity to bones, teeth and the whole body
3. They are part of soft tissues (muscles, protein and nervous tissues are made up of
sulfur and phosphorus).
4. They are components of essential hormones that contribute to healthy body system.
For example, iodine is present in thyroxine and zinc is in insulin.
5. They contribute to the body fluids and tissues as electrolytes concerned with the
maintenance of osmotic pressure, and acid-base balance. They also contribute to
membrane permeability and muscle irritability and oxygen transport (sodium,
potassium, chloride, phosphorus, calcium, magnesium and iron).
6. They are essential for blood clot formation
7. They are catalysts in enzyme and hormone system
8. They make possible normal rhythm in the heart beat.
Vitamins
Vitamins are group of organic substances needed by the body in minute quantities but
essential for normal metabolism, growth and development of the body. Vitamins like
proteins, fats, oils, carbohydrates are organic substances but they differ from the large
molecules. They are different because in their structures. Their individual units and are not
linked in long chains. Vitamins do not yield any end product; they assist enzymes that yield
glucose from carbohydrate, amino acids from protein and fatty acids, glycerol and glycerides
from lipids. The amount of vitamins needed are measured in micrograms or milligram instead
of grams used for the large molecules.
Classification of vitamins
Vitamins can be classified into two main groups. These two groups are fat and water soluble.
The fat soluble vitamins are generally stable to heat and they can only be transported in the
body in the presence of fat. The water soluble vitamins on the other hand, are not always
stable to heat. They are decreased by heat OR long storage.
 These fat soluble vitamins are vitamins A (Retinol), Vitamin D (Calcipherol),
Vitamin E (Tocopherol), and Vitamin K (Menadione).
 The water soluble vitamins are easily destroyed by heat. The water soluble vitamins
are vitamins B1 (Thiamin), vitamin B2, (Riboflavin), vitamin B5 (Niacin or Nicotinic

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 acid) vitamin B6, (Pyridoxine), vitamin B9 (Folic acid), vitamin B12 (Cobalamin) and
vitamin C (Ascorbic acid).
Water
Water is defined as tasteless, colourless, odourless, and clear fluid that is made up of
hydrogen and oxygen. Water can be classified as either hard or soft. Water is either hard or
soft depending on the source of the water. The two main source of drinking water are surface
and ground water. Surface water comes from lakes and rivers. The ground water, on the other
comes from underground rock. The vast majority of the people in rural and some parts of the
urban areas draw water from the well. The two sources of water are exposed to contaminated
wastes, pesticides, chemicals and poorly disposed household solvents. The level of chemical
present in water will determine the level of the hardness of the water.
Function of water
1. Water supports life, without it human being cannot survive.
2. Water serves as intracellular and extracellular fluid.
3. It forms a good medium for removing heat from the body because
4. It has great ability to hold heat.
5. It helps to remove waste products from the body.
6. It serves as lubricant in the knees and joints of the body.
7. It is used for the construction of every cell.
8. Water forms the major part of foods and human body.
9. It serves as a solvent for nutrients; it liquefies food so that it can be properly digested.
Effects of water on Nutritive value of food
The quantity of water in a food has a great effect upon other nutrients in such food. Fruits and
some green leafy vegetables, have higher quantity of water and lesser energy and other
nutrients than dried fruits and leafy green vegetables. The quantity of water, in other words,
affects the total energy value in the food because of dilution. The same principle applies to
protein and other nutrients. Recommended daily water requirement for water. You should
remember that almost two thirds of the body is made up of water, hence the need for daily
regular intake of water is compulsory. An average individual requires about two litres or
eight cups of water on daily basis. You should also note that water is also abundant in some
foods such as fruits and leafy green vegetables (cucumber, lettuce, raw tomatoes, orange,
grape, water leaf, okra). The body also makes its own water from the byproduct of
carbohydrates, fats and protein metabolism.
Fiber as an Essential Nutrient
Trowel (1972) defined dietary fiber, as “component of the plant cell wall that resists digestion
by secretions of the human eliminatory tract”. The life science research office (1987) also
defined dietary fiber as “the endogenous components of plant materials in the diet which are
resistant to digestion by enzymes produced by human”. Whitney, Cataldo and Rolfes (1998)
also defined dietary fiber as the structural parts of plants and are found in all plant – derived
foods – vegetables, fruits, grains, and legumes”.

Differences between Starch and Fiber

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In plants, glucose is stored as starch in the plant cell, just as the human body stores glucose as
glycogen. Although both starch and fiber are polysaccharides, fibers differ from starch
because the bonds between their monosaccharide units cannot be broken down by human
digestive enzymes. Starch, on the other hand, is digestive by human digestive enzymes. The
connecting chains in starch are in spiral form, whereas, in fiber it is straight.
Classification of Dietary fibers
Total dietary fiber can be broadly divided into two, non-starch polysaccharides and Lignin,
Lignin is a non-polysaccharides fiber that gives the plant its strength. Lignin is an insoluble
fiber; examples are whole grains, parts of vegetables such as carrots or the small seeds of
fruits. The non-starch polysaccharides are further divided into non-cellulose polysaccharides
and cellulose. Like starch, cellulose is made up of glucose units. They are connected in a long
chain and this chain does not branch. The bonds holding the glucose units together resist
digestion by human digestive enzymes. Cellulose is the primary constituent of plant cell walls
and hemicelluloses are the main composition of cereal fibers (wheat, brown rice, vegetables).
Both cellulose and hemicelluloses are insoluble in water. It is apparent from the above that
further division of dietary fiber can be grouped under soluble dietary fiber. The soluble
dietary fibers include peetins, guins, and mucilages. Pectins are found in vegetables and
fruits, especially citrus fruits, apples, banana, oranges, carrots, oats, and kidney beans.
Remember that gums and mucilages are the secretion that comes out when a branch of plant
is cut.
Functions or Health Benefits of Dietary Fiber and Food sources.
The health benefits of soluble dietary fiber include:
1. Delaying the stomach’s emptying and the transit of chime (through the intestine).
2. Delay glucose absorption
3. Lower blood cholesterol
The health benefits of insoluble dietary fiber include:
4. Speed up the transit of chyme through the intestine (whole grains)
5. Increase fecal weight
6. Slow starch breakdown and delay glucose absorption into the blood
Food Guide Pyramid
The food Guide pyramid was developed to help individuals to choose an adequate and
healthful diet. The food guide Pyramid shows at the base of the pyramid bread, whole grain
cereal, and at the top of pyramid are fats, oils, sweets meaning that to have an adequate diet,
one should eat more of the food at the base and consume very minimal of those at the apex of
the pyramid. In the middle of the pyramid fruits and vegetables are encouraged to be
consumed at least 2 to 4 servings every day. The third layer has meat and milk products and
they should be consumed at least 2 servings daily.
The importance of Food Classification
The advantages of Food grouping include the following:
i. It encourages consumers to eat healthily.
ii. It shows those food items consumers should be taking in enough quantity and
those that should be taken with caution.
iii. It describes the function of each nutrient at a glance (energy giving or body
building food groups).

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 iv. It serves as a graphic representation of those foods to be taken minimally. (sugar,
ice cream, and other sweets, the tip of food Guide Pyamid).
v. It shows number of servings attached to each group (food Guide pyramid).
vi. It provides daily food Guide.
Balance Diet
Balanced diet simply refers to an adequate meal that provides all the essential nutrients in
sufficient quantities to meet the need of the body. In other word balanced diet simply mean a
diet that contains all the required nutrients by the body in right proportion. That is why it is
expedient to have a basic knowledge of food group to enable one to know how and where to
select the meet of the body demand. The following hints guide in planning a balanced diet:
 Vegetables should be part of a diet as they provide valuable vitamins and minerals
 Prefer animals source of protein than plant sources unless you will combine two plant
sources of protein to complement each other.
 Variety is an important principle to follow in planning any diet.
 Thorough cooking destroyed micro-organism but to protein sources lead them to lose
their nutrient
 Some fat is needed for vitamin content and proper body regulation
 Drastic diet involving few or no carbohydrates may so deprived the liver for
glycogen that serious harm may result.
 The use of condiments like spices and pepper should be moderate, and just sufficient
to render food palatable. Their excess is irritating.
Food Preparation
Regardless of the methods used in food preparation, some nutrients are lost; especially water
soluble vitamins are lost during food preparation. The method of preparing corn pap for the
children through sieving of the wet milled corn, most of all the vital nutrients such as protein,
minerals and vitamins are lost. The frying of palm oil lead to the loss of beta-carotene in the
palm oil. That is the essence why people should understand the right way for preparing their
meals to avoid losing these useful nutrients.
Rationale for cooking foods
Homosapiens in the early century were food gatherers and they did not cook their foods until
later century. All their foods were eaten raw. The agricultural and industrial revolutions had
brought a lot of changes to both food processing and preparation. Most of the foods have to
be cooked for the following reasons:
1. Cooking of the food will destroy all pathogenic (disease causing) agents. Such as
bacteria and viruses.
2. Cooking the food such as meat, grains, (rice, wheat, maize, guinea corn, legumes
(beans, lima beans), and tubers will make these food items palatable.
3. Cooking the food makes the texture soft and easily, digestible and utilisable in the
body system.
Prior to cooking the food, the food items may have to be washed, hulled or peeled, chopped,
pounded, socked, or squeezed. Smoking, baking, roasting, grilling, stewing, steaming,
boiling, and frying of foods are methods of preparing food. Some of these methods have
adverse effects on human beings. Smoking leaves black smoke on the food, while frying may
lead to excess intake of fats in the body system. Excessive intake of fat may lead to

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cardiovascular disease or obesity. Of all the methods of preparing foods, boiling, steaming
and baking are acceptable because these methods help to preserve some vital nutrients in the
foodstuffs. Food borne illness is one of the major adverse effects of poor handling of food
during preparation. Prevention of food borne illness can be prevented by keeping hot foods
hot, cold foods cold and keeping hands, utensils, raw foodstuffs and kitchen clean. Meat and
seafood must be cooked very well. Keep cold food at 40 0F or less and keep frozen foods at
00F or less. Washing of hands and all cooking utensils before cooking will definitely help to
prevent food borne diseases. Salmonellosis is a food borne illness due to consuming raw or
under-cooked eggs, meats and dairy products. Hepatitis is also food borne illness caused by
eating under cooked or raw shell fish.
a) Milk and Milk Products
Milk is considered the most nearly perfect food among the food groups. Since bacteria
(micro-organisms) thrive well on milk, there is need to observe proper hygiene when it is
being handled. Pasteurization is a process by which fresh liquid milk is heated to at least
62.80C (1450F) for at least 30 minutes and then immediately cooled to 10 0C (500F). The
process kills all harmful bacteria and checks the growth of some harmful bacteria which can
cause milk to sour. It is recommended that milk be refrigerated in clean covered containers to
preserve its nutrient content and inhibit the growth of bacteria. It should be heated at low
temperatures because it scorches easily. In order to ensure safety, most liquid milk is usually
pasteurized.
When milk is allowed to coagulate, the curd formed is cheese. There are many hundred types
of cheeses, but the commonest type of cheese is the local cheese (cottage cheese (wara)).
Cheese is rich in proteins, minerals and vitamins. It is easy to digest and can easily be served
to a patient during convalescence. It can be regarded as a meat alternate.
b) Eggs
Egg protein is the standard by which all other proteins are measured. It is rich in the Essential
Amino Acids, minerals and vitamins. However, on account of their high cholesterol content,
it is advisable to limit eggs to 4 per week. Eggs should be stored with the small end down as
this keeps the air cell at the rounded end and prevents the yolk from slipping out of place.
They should be refrigerated until used. Eggs, like most foods, become ‘tough’ when cooked
at high temperatures.
c) Meat, Poultry and Fish
The combination of these members of the ‘meat’ group provides the greatest source of animal
proteins in the diet of man. They are also rich in minerals and vitamins. The types most
available in the Nigerian market include beef, veal, lamb, goat meat, pork and wild game
meats (hares, deer and grass-cutters). Organ meats, including liver kidney, tripe, tongue,
spleen and brain, are especially good sources of minerals and vitamins. But they are also
good sources of cholesterol.
The commonest types of poultry available in Nigeria are chickens, turkey and seasonal game
hen. In order to prolong the shelf life of these items, roasting and frying are used widely.
They exist as friend dried meat. On the other hand, sea foods may be two types: fish and shell
fish. The most popular are the fishes, most often, in the form of frozen, cured or smoked
types. Although the full potential of the fish industry is only now being realized, the
consumption of fishes is rapidly increasing in Nigeria.

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 d) Vegetables and Fruits
Vegetables are edible plants which provide vitamins, minerals, carbohydrates, and to a
limited extent, proteins. On the other hand, fruits are the fleshy parts surrounding the seeds of
plants. They contribute valuable vitamins, minerals, carbohydrates in the form of sugars and
cellulose and water. Because they contain cellulose, water and fruit acids, they have laxative
effect and are useful in overcoming constipation. Both fruits and vegetables are normally
consumed fresh, but can be preserved if refrigerated.
Fruit juices should be kept cold, covered and stored in opaque containers which block out
light, thus preserving their flavor and vitamin content. Fruit drinks (not juices) and
carbonated beverages usually contain only calories in the form of sugar and sometimes
additives. Fruits keep best when stored in the refrigerator.
METHODS OF FOOD PRESERVATION
Apart from fruits and salads man seldom eats food that is fresh and raw. Therefore, the need
for food preservation is highly enormous to minimize the rate of food spoilage. There are
traditional and modern methods of food preservation and processing in the kitchen and at
home. Today, there different food industries provide more varied and secure methods of food
preservation. The principal means by which food is preserved other than by addition of
chemicals are cold, heat, the exclusion of air, drying, salting and curing (smoking).
a) Preservation by Heat
This method of food preservation requires that will assist in exclusion of air using cooking
articles by enclosing the food in thematically sealed containers. The food items usually
preserved in this form of preservation are meat, fish, vegetables, fruits and milk. These foods
are properly packed and filled and latter placed in a retard and steamed for a time sufficient
effect sterilization and suitable cooking, after which they are sealed. Food preserved in this
way are carefully selected all un-sound or blemished portion been eliminated. The container
may be of glass or earthen wire but are usually of metal product.
Evaporated and condense milk are usually been preserved in this way. In evaporated milk
nothing but water is taken from the milk and nothing is added while in the latter sugar is
added after the water content is evaporated.
b) Preservation by Cold
Maintenance of food in temperature at just above the normal freezing point is the appropriate
method of food preservation. Because in chilling, for example, the normal physical state of
food is preserved while in preservation of meat, but they are suitable also for fish, poultry,
game and eggs. The period during which chilling is effective is limited to about three weeks
but freezing is practicable and effective for more number of weeks.
c) Preservation by Curing (Smoking)
The process of smoking is usually preceded by salting and some amount of drying either in
open air or in a warm temperature prior to smoking. Examples of foods preserved under this
method are beef, mutton and bacon fish. Smoke is produce by fire wood and timber saw dust.
The length and time for which meat may be preserved by curing depends on the degree to
which the process of salting and smoking are carried out.

d) Preservation by Drying

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Vegetables, fruits and sometime meat and fish are been preserved in this form. Though that
fruits and vegetables are the principal foods preserved in this way. Fresh foods like beans,
grains are also treated in this form. Nothing but water is removed from the food and it must
be replaced before consumption. The organisms responsible for food spoilage yeast molds
and bacteria are not necessarily killed by drying and they may restore their activity when
food is rehydrated. It is important to use the food immediately after rehydration.
e) Preservation by Canning
After processing foods such as fish, meat, fruits, vegetables are preserved in cans and can
stay for long without getting spoiled. Food canning plays an important part in inter-change of
food between one country and another.
NUTRITION OF THE CHILD
Without doubt, the status of the nutrition of a child impacts on the future and subsequent
generations. In recent years, the nutrition of a child has occupied the centre stage of the
economic development of a nation. This is because the nutritional requirements of infants and
children reflect a population’s unique needs for growth and development. On account of the
fact that the metabolic rate of infants and children are greater and the turnover of nutrients
more rapid than those of adults, these need usually superimpose upon, and do take
precedence over, the maintenance needs of the child. Unfortunately, the provision of these
greater needs is hindered by the baby’s physiological limitations of lack of teeth and limited
digestive and metabolic processes.
At birth, a baby has sufficient store of brown fat and glycogen that can be metabolized to
produce heat for the maintenance of body temperature. Nevertheless, the nutritional
importance of the food given within the first few hours of life is to maintain a safe blood
glucose level and to initiate milk-flow. After the first few days, however, the provisions of
sufficient calories for growth purposes become more important. By the end of the first week,
the rate of growth and weight gain of the infant is faster than at any other postnatal time,
when the baby gains between 180 and 210 g per week. In order to achieve this, at least 1.5 g
per kg per day of proteins is required with sufficient calories from carbohydrates (lactose) in
the milk. At this time, approximately one-third of the total caloric intake is expended for
growth. Therefore, an inadequate energy supply at this time will decrease weight gain, but
brain growth may be spared unless energy intake is grossly deficient. However, the
uncertainty that surround brain growth at this stage of an infant’s development, coupled with
the persistently high incidence of neuro-developmental deficits in surviving Low Birth
Weight infants, suggests that better nutritional management not only might decrease mortality
but also might improve neuro-developmental outcome.
Human milk contains appropriate amounts of all necessary nutrients, including the Essential
Fatty Acids, arachidonic and linoleic acids needed for optimal brain development. The
amount of food required by each baby depends on the rate of metabolism, how active the
baby is and on the need to produce heat to keep him warm. Additionally, a baby whose
intrauterine growth was reduced may need to make up by a ‘catch-up growth’, thus requiring
additional nutrients. Fortunately, all healthy babies usually obtain the needed amounts of food
by letting their mothers know when they are hungry or satisfied.
Feeding the Pre-Term (Low Birth Weight) Baby
The increasing number of surviving LBW infants that must be fed has heightened the

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awareness of the problems encountered in meeting their nutritional needs. The importance of
adequate early nutritional management of the LBW infant can be illustrated by considering
the energy metabolism of the fasted infant. In such infants, the ultimate determinants of the
length of time they can survive depend on the adequacy of hydration, and the available
endogenous stores of fat and protein.
The most generally accepted goal for nutritional management of the pre-term (or LBW)
infant is to provide sufficient amounts of all nutrients to support continuation of the
intrauterine growth rates. But there is currently a new problem of feeding the small pre-term
baby. The common practice of feeding pre-term infants with human milk was abandoned
some 50 years ago, following the demonstration that protein intakes that are higher than those
provided by human milk resulted in a greater rate of weight gain. It is natural that once
feeding has become established in a baby weighing 1 kg or less, it should be given sufficient
food to enable it to grow at the same rate as it would have done had it not been born. It is also
known that breast milk is best in most circumstances. But for the pre-term babies, however,
breast milk is inadequate in several respects. The growth rates of these babies fed human milk
are considerably lower than those of infants fed formulas. This can be ascribed, in part, to the
relatively low protein concentration of human milk. There is also evidence to show that
breast milk cannot supply the infant with as much calcium and phosphorus as it would have
obtained from its mother’s circulation. Breast milk also has some short-comings as its sodium
content is grossly inadequate. Fortuitously however, milk of mothers who deliver pre-
maturely has an appropriately 20% higher protein concentration and supports desirable
growth rates in the premature babies. An infant weighing 2,000 g at birth has more extensive
endogenous nutrient reserves than one weighing 1,000 g; and an infant weighing 3,500 g has
more extensive reserve than one weighing 2,000 g. Thus, the smaller the infant, the more
marked is his inability to withstand starvation. The term baby has sufficient reserve to survive
a total starvation condition for approximately a month.
For pre-term infants weighing between 0.5 and 1.0 kg, the intake of sodium from breast milk
does not meet the requirements for growth, and for infants between 1.0 and 1.5 kg, it barely
does so, even if all the sodium intake is absorbed and retained. Furthermore, the amount of
iron in human milk is nowhere near enough to meet the requirements, and the amount of
copper is almost certainly inadequate. The large reserve of copper in the liver of full-term
infant, amounting to more than there is in the rest of the body, accounts for the rising
increment, which is needed to meet the copper requirement of the term infant during the first
few months after birth. The small pre-term infant lacks these reserves.
Normal Infant Feeding
All babies thrive on their mothers' milk. While breast-feeding is universal in the rural areas
of Africa, its importance has been diminishing in the cities, especially among the “affluent”
mothers. In most communities, breast-feeding is universally accepted as the best means of
delivering nutrients to the newborn. But a mother must be encouraged to feed adequately,
exercise, rest and have freedom from anxiety in order to fulfill this function. Approximately
120,1 Kcal is required for the synthesis and secretion of breast milk during the first 6
months of the infant’s life. The increased caloric allowance for the nursing mother, in effect,
translates into her ‘eating for two’ human beings. On account of its ready availability, its
relative safety and the promotion of enhanced resistance to infection and bonding between

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the mother and infant, human milk is usually the perfect food for the normal infant. However,
infant feeding does not occur in isolation, but as a part of a complex of interlocking social
and biological conditions. For example, if a woman must return to work almost immediately,
or she dies soon after childbirth, the only practical decision may well be to feed the baby
‘artificially’. On the other hand, an infant who has a strong familial history of allergy may
have no alternative to breast-feeding. The human intestinal wall is more permeable to cow's
milk than to breast milk, thereby increasing the risk of allergy. Furthermore, since only about
1% of all women who decide to breast-feed experience any kind of failure, it is unfortunate
that, in spite of its many positive qualities, there is a general decline in its usage, thus
constituting a loss of valuable natural resource that has been well-recognized as a major force
in the prevention of malnutrition in children.
Nutrition after birth is a less efficient process than nutrition before birth for two reasons:
firstly, there is inevitably more wastage when nutrients are absorbed through the intestines
than when they are delivered directly into the blood stream through the placenta; and
secondly, but more importantly, a great deal of the energy taken in the milk is used for
maintaining body temperature in an environment that is usually cooler than the uterus. During
the first two months of life, only about 25% of the total intake of energy goes towards
producing new body tissues, and by 4-6 months, the percentage has fallen to 8 - both in
breast-fed and bottle-fed babies. Health and nutrition education should be coupled with
emphasis on adequate breast-feeding and safer and adequate supplementary feeding with
locally available weaning foods. In this regard, it is necessary to convince parents and most
Nigerian health workers that the unfortified pap is 90 to 95% water and low in total energy
and proteins. Thus, breast-fed infants from populations at risk of PEM should be weaned with
reinforced home-made paps as soon as the growth curve begins to flatten (not on account of
diarrhea or pyrexia), the baby cries more often than usual, is restless and sleeps less, often
waking up intermittently.
The period of neonatal life and early infancy is characterized by rapid growth. But the human
infant grows less rapidly than the young of other mammals. For example, a calf doubles its
birth-weight in one month; whereas an average baby doubles its birth-weight in 4 to 5
months, and triples it in about 12 months. Birth-weight doubling time is usually considered to
take place around 5 to 6 months, but current data indicate a trend towards faster weight gain
among babies. Some authors have reported an average birth-weight doubling time of 119
days (3.8 months) for American children. Formula-fed babies doubled their birth weight
earlier than did breast-fed ones (113 versus 124 days). However, a general trend towards an
increased rate of weight gain in infancy may contribute to later problems of obesity. This
rapid growth is brought about by increased muscle mass, growth of organs, expansion of
blood volume and linear increase in the long bones. The breast milk alone in the first 3 to 4
months of life supplies the nutrients required to sustain such a growth for practically all
children. The compositions of human milk therefore provide a clue to the physiological needs
for these nutrients and for energy in the infant.
Nutritional Requirements during Infancy
For an infant, food is both a source of nutrients as well as a source of nurture. When a baby is
bottle-fed or breast-fed, food and love become synonymous. But the needs of both the mother
and her child must be taken into consideration in deciding which mode of feeding is best; and

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with breast-feeding; encouragement should be given wherever possible.
Soon after birth, but not later than 4 hours, a normal full-term healthy baby should be put to
the breast. Such a baby is capable of being put to the breast immediately after birth, however,
and this should be encouraged. If no breast milk is forthcoming, as in the case of a baby
whose mother dies soon after child-birth, the baby may be put to 10% dextrose, or 5%
sucrose or plain water. However, no effort should be spared to initiate breast-feeding.
Eating is an activity in which babies play an active role, unlike bathing, clothing, etc. This
activity involves three mechanisms: rooting (searching for the nipple), sucking (continuous or
intermittent) and swallowing (well-coordinated with breathing, allowing milk to go to the
esophagus instead of the lungs). Nutritive suckling behavior in the new born is affected by
obstetric sedation, with the infant suckling at significantly lower rates and pressures and
consuming less. This lack of responsiveness should be recognized quickly since this can
interfere with nutrient intake and the developing mother-child relationship, as anxiety,
tension or frustration, on the part of the mother, can negatively reinforce the infant's early
feeding experience. In the first year of life, an infant progresses from a totally dependent
(passive) feeder to that of an active participant with a fair amount of independence. This
follows the sequence of head, trunk, gross and fine motor control as the infant's reflexive
behavior becomes voluntary, e.g. chewing and swallowing rather than sucking solid foods, or
drinking from a cup.
It is now well-established that the human milk is the best food for infants and will meet the
nutritive requirements of early life when it is supplied in sufficient quantity. In general, the
breast milk from a well-nourished mother alone is sufficient to meet the infant's nutritional
needs in the first 3 to 5 months of life. Where infant formula must be used, sterilized
formulas, which have been processed to simulate human milk, together with vitamins and
iron supplements, can also meet the infant's needs. Growth is rapid and nutrient needs parallel
growth. Fortunately, the typical African breast-fed child shows good growth during the first
six months which is equal to, or even better than, that of children in the highly-developed
countries.
Thus, cow's milk or skim milk is not the most suitable food for infant feeding. With early
attempts at formula-feeding, as much as 95% of infants fed mammalian milk died in the first
two weeks of life, due to protein intoxication, diarrhea, dehydration, hyper-electrolytemia and
death. Even present attempts are still producing high (50%) mortality rates among artificially
fed infants in developing countries (in homes where bacterial contamination or incorrect
formula preparations are common). Where there is refrigeration and little or no contamination
of water, death from artificial formula feeding may be reduced to a level similar to that of
breast-fed infants. In such cases, formulas are usually fortified with vitamins C and D, iron
and other nutrients, decreasing the incidence of rickets, scurvy and iron-deficiency anemias
such that there is little distinction between individual breast-fed and formula-fed infants.
However, breast milk remains the preferred food for the human infants (though mothers who
choose to feed their infants with formulas should not be made to feel guilty, once necessary
precautions are taken). Human milk contains more lactose, iron, vitamins A and C per unit
volume, but less protein, calcium, phosphorus, riboflavin and thiamin than cow's milk. One
must conclude from these compositional differences, that each mammalian milk is adapted to
provide the best nourishment for the young of each species.

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When should weaning begin?
The debate on when exactly to introduce other foods besides breast milk continues to rage
on. Weaning has been defined as the period which extends from the time when the baby is
solely breast-fed until he is feeding entirely on the adult diet. Several studies for and against
an early introduction of other foods have been presented. Socio-cultural factors are often
ignored when this debate is tabled. There is no doubt that the debate is not founded on
physiological one but more on the socio-cultural practices. As pointed out in another section
of this presentation, the aim of a more reasonable and scientific approach is to allow mothers
to make informed choices on how to feed their infants and support them in their decisions.
This scientific approach is to observe the following conditions as a guide to the introduction
of other foods. When the growth curve begins to falter, and the child sleeps far less than usual
because he has to wake up to feed frequently, it might well be a sign that breast milk is no
longer adequate. If such a child does not have a fever or a diarrhea, the mother should be
encouraged and educated on how to introduce supplementary feeding.
Exclusive Breast-Feeding In the First 6 Months of Life
The belief that human milk has a fairly constant composition, especially in terms of its
carbohydrate, protein, fat, calcium and iron content, and is little affected by the diet of the
mother, and that human milk is the ideal food for the human infant needs to be qualified. A
mother whose diet is deficient in thiamin, vitamin A and ascorbic acid, produces less of these
nutrients in her milk, and in the case of thiamin, this can lead to infant beriberi. Nevertheless,
the effect of very poor nutrition on a lactating mother is to reduce the quantity, rather than the
quality, of the breast-milk. However, many infants also grow well when fed cow's milk or
formulas that are different in composition from human milk (see Table 6.2 below). Although
the economic advantages and microbiologic safety of breast-feeding for less developed and
less affluent societies are obvious, these factors are less important in affluent, developed
societies in which the current generation was fed artificial formulas during infancy. Thus, a
more reasonable and scientific approach is to allow mothers to make informed choices of
how they wish to feed their infants and support them in their decisions. Although a baby is
born with the full complement of oligosaccharidases, starch should not be given to new born
infants because the small amount alpha-amylase produced by the pancreas cannot be
sufficient to hydrolyze the starches. Furthermore, the size of the baby’s stomach is rather too
small to accommodate bulky starches.
(1) Cow’s milk contains more than three times as much proteins as human milk;
(2) Human milk is two times as high in carbohydrates as cow’s milk;
(3) Calcium levels are appropriately four times higher and phosphorus content, six times
higher in cow’s milk than in human milk; and
(4) Cow’s milk is approximately four times higher in riboflavin content than human milk.
Breast-Feeding Versus Bottle-Feeding
It was the famous pediatrician, Paul Gorgy who once remarked that the "cow's milk is best
for the baby cow and the human milk is best for the human babies." Fortunately, it has been
estimated that 90-95% of mothers are fit and capable of breast-feeding their babies.
Although, science and industry have combined their skills to produce cow-milk products that
contain nutrients in qualities that are similar to those in breast milk, statistical advantages of
breast feeding persist. Nevertheless, formulas have been modified to approximate human

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milk such that little distinction can be observed between the breast-fed and the formula-fed
infants. Thus, the overall nutritional superiority of breast milk (its ability to provide the
nutrients) over cow’s milk or its products is not in doubt, at least for those who cannot afford
these products or who do not live under modern conducive conditions. Thus, there is no
doubt that none of these products or the milk of other mammals is, overall, as good as the
human milk for the human infant. And the breast milk remains the preferred food for human
infants; but in the former cases, as in the studies carried out in Boston, rural Sweden and
Kuala Lumpur, where the formula has been properly selected and prepared, few differences
were noted in the well-being of the breast-fed and bottle-fed infants. Therefore, mothers who
choose to feed their infants with formulas should not be made to feel guilty, if they can afford
to do it properly.
Advantages of Breast Feeding
a) Breast-feeding gives a safe and protected feeling to the infant and a sense of satisfaction to
the mother. It promotes a feeling of closeness to the baby, thus fostering good mother-child
relationship. For some nursing mothers, the great satisfaction of providing food for a small
new life from one's own body, coupled with a strong sense of feminine identity and capacity
which may be evoked, are powerful incentives to maintain the nursing role for as long as
possible. Paradoxically however, these same factors may lead to a wish to remain the sole
source of the infant's food beyond the limits of nutritive reality. Thus, a well-intentioned
prolongation of breastfeeding may unwittingly cheat the infant of needed nutrition.
b) Secondly, there is a reduced likelihood of diarrhea. The stools of infants fed breast milk
have lower pH (5.4) than those fed cow milk (6.9). The higher pH permits greater growth of
pathogenic bacteria in the GI tract. In the lower socio-economic groups, breast-fed infants
have a consistently lower mortality rate, perhaps because the problem of sanitation is
eliminated. In addition, constipation occurs less frequently.
c) Breast-feeding confers immunity on the child on account of the immunoglobulins (Ig) and
other constituents of breast-milk. The human fetus obtains its IgG antibody before birth from
its mother's circulation, but gets its IgA from the colostrum. This colostrum contains about
11.5% IgA; but by the 4th day, this has fallen to 0.75% and in the mature milk, the
concentration of IgA is about 0.1%. IgA, among other agents, acts in the intestine and limits
the multiplication of bacterial and viral pathogens within the digestive tract. Thus, it
promotes a bifido-bacterial flora in the infant’s intestines that is antagonistic to certain
pathogens.
d) Human colostrum and, to a less extent, mature milk, contains other substances which are
important for the infant. For example, they contain lactoferrin, which, by binding iron, makes
it unavailable to E. coli in the intestine, thus inhibiting their growth. Colostrun also contains
other nutrient binder proteins, which act similarly to lactoferrin for such micronutrients as
zinc, vitamin B12 and folate. Thus, the enzymes, hormones, immunological factors (IgA) and
other substances in the breast-milk positively affect digestion, absorption and utilization of
nutrients as well as resistance to enteric and respiratory diseases and to allergy. Thus, as a
rule, based on the foregoing, there are fewer and less serious illnesses and feeding problems
among breast-fed infants.

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e) Breast milk is readily available and convenient. On a practical basis, breastfeeding
eliminates preparation; it is available at a proper temperature and also avoids errors in
calculation and in formula preparation.
f) The human breast milk is nutritionally superior to any other infant food. For example, an
enzyme which aids protein digestion has been found in greater supply in human milk than in
cow milk, hence breast-fed infants are rarely constipated. Furthermore, taurine, a rare amino
acid involved in the transmission of nerve impulses, particularly in the eye and the beating of
the heart is present in the human but absent in cow milk. Also, lactose aids the absorption of
Ca, Mg and amino acids. Upon its digestion, it yields galactose which is an essential
structural component of the nervous system of the neonate. When the milk of other mammals
is used in the formulation of some commercial foods, this lactose become diluted and
inadequate. Furthermore some commercial formulas substitute syrup or sucrose for lactose.
Since neither of these yields galactose on hydrolysis, a deficiency of galactose may affect the
development of the nervous system of the neonate. In addition, the Polyunsaturated Fatty
Acids (PUFAs) in the human milk is not normally used as a major source of energy, but are
incorporated into cell membranes and are the precursors of prostaglandins which are involved
in many functions, such as regulating the transmission of nerve impulses and controlling
blood pressure and digestive processes. It is therefore undeniable evident that no other food is
equal to that of the human milk for the proper nutrition of the child provided a mother has
maintained adequate nutrition herself during pregnancy. The nutritional needs of the infant
are better met by human milk than by any substitute, and breast milk is yet to be improved
upon as a reference standard. Thus, efforts to duplicate human milk by alteration of the
components of cow's milk have not yet been successful. Besides, children who are breast-fed
have lower chances of becoming obese than bottle-fed children.
f) Breast-feeding confers an economic benefit on the family and the nation since breast milk
is the only low-cost high protein food of animal origin which is readily available, especially
in times of economic recession and restricted importation of baby foods.
g) Breast feeding has contraceptive effect on, and can delay the return of, ovulation by as
much as 5 to 8 months. Thus, wider spacing of children, resulting from breastfeeding is
perhaps having a greater influence on population growth than the pill or the IUD. In some
cultures, sexual intercourse is forbidden during breast-feeding, thus having an added
beneficial contraceptive effect on the mother.
Despite attempts by food chemists to modify the milk of the cow to feed the human baby,
which have been largely unsuccessful, notwithstanding the claims made by promoters of
products, the history of artificial feeding of infants is full of examples of one mishap after
another. Products which are promoted as ‘ideal foods’ are withdrawn from the market after a
few years later when their short-comings are exposed, only to be replaced by another family
of products, which are again, promoted with equal vigor. Nevertheless, epidemiological
observations showed that the following health problems occurred following the feeding of
such ‘artificial’ milk products:
- There were widespread outbreaks of rickets in the early part of the century;
- There were cases of neonatal tetany in the early 50s;
- There were reported cases of pyridoxine deficiency also in the late 50s and early 60s;
- Haemolysis due to vitamin E deficiency were also recorded;

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 - Risks of high plasma sodium (hypernatremia) have also been noted in recent years.
Furthermore, many of the dangers of artificial feeding arise from errors in reconstitution
(quality of constituted milk varies by as much as 20-30% from that recommended by the
manufacturers). In the affluent homes, over-concentration can lead to infant obesity. Thus,
the factors responsible for the decline in breast-feeding include Western influence, medical
advice and a strong advertisement and promotion of bottle-feeding. The latter being perhaps,
the most potent of all. On account of an intensive promotion by manufacturers, and in the
absence of a strong professional support for breast feeding, many mothers take to artificial
feeding only to find that the family income is inadequate to support the cost of powdered
milk (often, costing as much as one-third to one-half of the wages of the family to feed an 8-
month old baby). The temptation therefore, is to ‘stretch’ the tin of powdered milk with
consequent under-feeding - accompanied by a high incidence of marasmus.
The gut flora of the artificially fed infant is made up largely of E.coli, with some
Streptococcus feculis, in contrast to the breast-fed infant in whom the lactobacillus
predominates. The E.coli constitutes a reservoir of potential pathogen. The immune factor in
breast milk keeps the population of E.coli low until the baby has developed his own
immunity (thus the breast milk protects as well as nourishes, and the mammalian gland
performs functions similar to those of the placenta in the intrauterine life).
Militating Factors against Breast Feeding
Breast-feeding may not be encouraging if:
(a) For any reason, the mother's milk production is less than half of the infant's needs;
(b) The mother suffers from some chronic illnesses such as cardiac disease, tuberculosis,
severe anemia, nephritis, epilepsy, leprosy, insanity/psychosis, chronic fevers and the
internationally famous AIDS.
(c) Another pregnancy occurs, although hormonal changes brought about by the pregnancy
does not stop breast milk flow; it could lead to a maternal depletion syndrome.
(d) It is necessary for the mother to return to employment outside the home; or
(e) The infant is weak or unable to nurse because of cleft palate or hare-lip.
(f) Temporary cessation of breast-feeding is indicated when the mother acquires an acute
infection which the infant has not yet acquired.
The commonest ‘local’ cause of breast-feeding failure, however, are mastitis and breast
abscess. In such a situation, the breast may become so painful that suckling becomes
impossible, and unless the milk is drawn off, especially if the baby suckles the other breast,
thereby stimulating milk secretion in both breasts, the condition may become worse. When
this condition is promptly treated, it is seldom necessary to stop breast-feeding or nurse the
fear that the baby might be infected through the breast milk. On the other hand, failure to
institute therapy may result in serious breast abscess formation, which may lead to the death
of the infant, either through direct infection or as a result of losing breast milk supply.
In spite of the contra-indications, bottle-feeding has become a major public health problem in
the developing world for the following reasons:
a) Over-dilution of formulas in these economically-depressed areas of the world usually
leads to marasmus. Under-dilution can precipitate childhood obesity.
(ii) The poor environmental sanitation in such places leads to diarrhea. Thus, danger
signals have been sent out by the WHO and other International Agencies regarding the

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dangers of artificial feeding, especially in the less developed parts of the world.
Common Complications of Breast Feeding
Suckling Failure
Since successful lactation is a joint endeavor between a mother and her baby, any failure that
arises must come from maternal as well as neonatal causes or a combination. For example,
failure could be due to severe maternal ill-health, malnutrition, abnormal nipple (retracted, or
very large and pendulous), psychosomatic impairment, congenital abnormalities (cleft
palate), cerebral birth trauma, severe general infection (septicemia, meningitis, tetanus
neonatorum), dehydration fever or hunger diarrhea).
Mothers who keep their babies on the breast alone may subject their babies to “breast
starvation”. Now, weaning is the transitional process between breast-fed adequacy and the
full adult diet - a time of accustomizing to new foods and to lessening dependency on breast
milk. Unfortunately, the weaning foods commonly used in many parts of Africa range from
gruel pap (2% low quality proteins), used in Western Nigeria, to boiled yam in the Eastern
region of Nigeria and steamed plantain in Uganda. In other parts of the world, cereal- and
legume-based weaning foods are the norm. Table 5.2 (shown below) indicates the proximate
composition of certain weaning foods.
Gastric motility is poorly coordinated in the first few weeks of life, leading to poor antral
mixing and therefore less digestion of solid foods. By the 12 th week of age however, intestinal
peristalsis of a type seen in older children and adults develops, but it is about one- third
slower. This slower transit time may serve to increase exposure time to the intestinal mucosa,
thereby improving nutrient digestion and absorption.
Indeed, intestinal mucosa permeability is greatest during the neonatal period and many large
molecules, including proteins, tend to be absorbed intact. The intestinal mucosa alpha-
glucosidases (sucrase, maltase, isomaltase) are well developed by 32 weeks of gestation and
are present at near adult level at term. Intestinal amylase needed for starch digestion may not
reach adequate level until several weeks after birth. However, for the extremely premature
infants (27-32 weeks gestation), formulas with less than 60 % of total carbohydrate calories
as lactose are generally best tolerated. Although by six weeks, its ability to concentrate
solutes is close to adult levels, yet the kidneys have limited ability to dispose of urea
produced by protein metabolism and an excess intake may result in increased morbidity and
mortality associated with uremia in the baby.
Protein Energy Deficiency Diseases Found In Nigeria
The biological and socio-economic basis of certain nutritional diseases cannot continue to be
ignored in Nigeria as our ignoring them may explain why some of these diseases have not
been overcome, despite decades of efforts to reduce mortality and morbidity of these
diseases. Perhaps, a better understanding of their etiology would assist health workers to
overcome them. This has become vitally important as it has become clear that many members
of the health profession currently wallow in unbelievable ignorance about human nutrition. In
a previous segment of this course, we defined a nutritional disease as one, which occurs as a
result of an inadequacy or excessive intake of a nutrient. In this unit, we shall discuss the
energy-related diseases, namely, protein-energy deficiency diseases, namely, Low Birth
Weight, Kwashiorkor and Marasmus. In consonance with this, the objectives of this study
shall be as follows.

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Kwashiorkor
Kwashiorkor is a severe clinical syndrome caused by a deficiency of protein. Although
Kwashiorkor can occur even when the intake of energy is adequate, it has been shown that
diarrhea and infections were often the precipitating causes of kwashiorkor, as there is no case
of kwashiorkor without a history of infections. Thus, the following mechanisms may be
involved: Firstly, the infections may divert the meager amino acid pool to the production of
globulins and acute phase reactant proteins, instead of albumin and transport proteins.
Secondly, the increase of acute phase reactant proteins which are proteinase inhibitors may
impair muscle protein breakdown. Thirdly, an impaired production and utilization of ketone
bodies for energy during infections might lead to the use of more amino acids for
gluconeogenesis. Now, protein catabolism and nitrogen losses are enhanced by many viral
and febrile infections, probably through increased epinephrine and cortisol actions.
Regardless of the mechanisms involved, protein losses during severe infections can amount
to as much as 2% of muscle protein per day. Kwashiorkor occurs mainly among children
between the ages of six months and three years, with the second year of life being the most
vulnerable period. This coincides with the weaning period in which, as indicated earlier, the
baby’s diet is low in total energy and good quality protein, at a time when he most needs
protein for growth and the formation of muscle tissue.
The characteristic symptoms of kwashiorkor are painless, pitting edema, lack of growth,
muscle wasting with the retention of some subcutaneous fat, and psychomotor changes. With
these changes, the patients are usually apathetic and irritable. They cry easily and do have an
expression of misery and sadness. It is well documented that edema is the cardinal sign of
kwashiorkor and the syndrome should not be diagnosed in its absence. The accompanying
fluid accumulation was once believed to be due to the fall in serum albumin that accompanies
severe kwashiorkor. According to this belief, as the serum albumin drops, the osmotic
pressure also drops, and so fluid passes from the blood into the tissues. However, this belief
does not explain why children being treated for kwashiorkor lose their edema before their
blood protein level rises.
Although the classic theory of dietary cause of kwashiorkor (a diet of low protein-to-energy
ratio) is still valid, recent report shows that symptoms result from an imbalance between the
production of toxic free radicals and their safe disposal. Among the factors that increase free
radicals production are infections, toxins, sunlight, trauma and catalysts such as iron. The
toxic effects of free radicals would be responsible for cell damage, leading to the noticeable
alterations such as edema, fatty liver and skin lesions. This theory has drawn attention to
factors and processes in the pathogenesis of severe PEM and may have important
implications for its treatment. Accordingly, when there is a severe lack of food, endocrine
adjustments mobilize fatty acids from adipose tissue, and amino acids from muscle tissue,
thereby maintaining normal plasma protein concentration; but hepatic gluconeogenesis is
enhanced. An increase in carbohydrate intake without a concomitant increase in protein
intake can produce a breakdown of these adjustments. Thus, carbohydrates intake induces
insulin release and a reduction in the production of epinephrine and cortisol. A high-
carbohydrate, low-protein diet is not the only iatrogenic cause of serious metabolic disruption
in patients who have or are prone to develop edematous PEM. The abrupt administration of
excessive protein to patients with edematous PEM can also have serious life-threatening

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consequences. Lipolysis (fat mobilization) decreases and the action of insulin is enhanced on
account of the suppression of the inhibitory effects of free fatty acids on the peripheral action
of insulin. Muscle protein breakdown is also decreased, thus lowering the body pool of free
amino acids. The decreased synthesis of plasma proteins (especially albumin) in the liver
reduces intra-vascular osmotic pressure. Plasma water decreases and accumulates in
extravascular tissues; tissue pressure rises and cardiac output diminishes, thus contributing to
the appearance of edema. The increased hepatic fatty acid synthesis from the excess
carbohydrate impairs lipolysis, but increases fatty infiltration of the liver and consequent
hepatomegaly.
The pathogenesis of edema in severe kwashiorkor is an important issue because of the key
role of edema in its diagnosis, and because it may give clues to a patient’s dietary background
and other precipitating factors of the disease. This phenomenon has been linked to hypo-
albuminemia through a reduction in osmotic pressure of the plasma, leading to an outflow of
fluid from the capillaries into the interstitial space. However, there is an overlap in serum
albumin levels between edematous and non-edematous kwashiorkor in both adults and
children. But since the edema of kwashiorkor is reduced on treatment with protein-free or
low protein diets that contain potassium and other minerals and moderate amounts of
carbohydrates, it suggests that hypo-albuminemia may be a necessary but not a sufficient
cause of edema, at least in some cases.
An associated theory for the production of edema in kwashiorkor involves a reduction in
renal blood flow (RBF) and glomerular filtration rate (GFR) due to decreased plasma volume
and decreased cardiac output as consequences of hypo-albuminemia. This decrease in RBF
and GFR results in sodium retention and production of rennin and aldosterone, which would
increase tubular reabsorption of sodium and water, leading to edema. From these various
theories, it is possible that the pathogenesis of edema in kwashiorkor is not a single entity,
and that it may differ in accordance with the associated multiple nutritional deficiencies, the
age of the patients, and other concomitant conditions.
Infections in undernourished children can precipitate the onset of kwashiorkor by the
following proposed mechanism: (a) Infections may divert the meager amino acid pool to the
production of globulins and acute phase reactant proteins, instead of albumins and transport
proteins. (b) An increase in the production of acute phase reactant proteins inhibits
proteinases that may, in turn, impair muscle protein breakdown. (c) An impaired production
and utilization of ketone bodies for energy during infections might lead to the use of more
amino acids for gluconeogenesis. (d) Additionally, protein catabolism and nitrogen losses are
enhanced by viral and many febrile infections probably through an increased epinephrine and
cortisol actions.
Patients with severe energy deficiency are usually unable to maintain their supply of tissue
and cell energy supply and a serious decompensation occurs causing hypoglycemia,
hypothermia and impaired circulatory and renal functions, which results in acidosis, coma
and death. These events can occur within a very short time. Thus, a premature introduction of
a high-energy or high-protein diet may be fatal to a severely malnourished patient.
Marasmus or Simple Starvation
This is an extreme form of under-nutrition in which due to the lack of calories and proteins.
The consequences of this condition are generalized muscle wasting and the absence of

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subcutaneous fat, which gives the “skin and bones” appearance. The children often have
marked retardation in longitudinal growth, a lack of physical wellbeing, abnormal behavior
and poor mental development. The hair is sparse, thin and without the normal sheen. The
cheeks are sunken by the disappearance of the Bichat fat pads (which usually gives shape to
the face), giving it the appearance of a monkey’s or little old man’s face.
After the ingestion of a meal, food energy is stored, mostly in the form of high-energy
phosphates, fat and glycogen which are drawn upon to obtain energy during the daily regular
and relatively short periods of fasting and during periods of increased energy expenditure.
Marasmic condition usually develops rather slowly to allow for better adaptation to energy
inadequacy. Normally, a decreased energy intake is quickly followed by a decreased energy
expenditure, which account for shorter periods of play and physical activity in children, and
for longer rest periods and less physical work in adults. When the decrease in energy
expenditure cannot compensate for inadequate intake, body fat is mobilized, at a faster rate
than lean body mass, with a decrease in adiposity and weight loss. Lean body mass
diminishes at a slower rate, mainly as a consequence of muscle protein catabolism. The
catabolic product of this process contributes to the body’s energy sources, but causes muscle
wasting. As the cumulative energy deficit becomes more severe, subcutaneous fat is
mobilized and used by the body. These alterations in body composition initially lead to an
increased basal energy consumption and increased basal metabolic rate, which later decreases
in the more severe stages. In the meantime, blood glucose concentration remains normal at
the expense of gluconeogenic amino acids and glycerol from fats.
In situations where dietary proteins are of poor quality, body proteins will not be synthesized.
As the individual gets maximally adapted, the consequent sparing of body proteins preserves
only the essential protein-dependent functions. The gradual and inevitable body protein losses
resulting from this long-term dietary protein deficit come mainly from skeletal muscle
breakdown. Some visceral protein is lost in the early stages, but soon stabilizes until the
nonessential tissue proteins are depleted. The loss of visceral proteins now accelerates and
death may be imminent unless nutritional therapy is quickly instituted.
Under normal circumstances, some 75% of the free amino acids entering the body pool from
dietary and tissue proteins are recycled or reutilized for protein synthesis. The remaining free
amino acids are broken down for other metabolic purposes. When protein intake is reduced
there is an adaptive decrease in amino acid turn-over rate and a proportional decrease in
amino acid catabolism. This markedly reduces urea synthesis and urinary nitrogen excretion.
Furthermore, there is a shift of albumin from the extra-vascular to the intra-vascular pool,
which assists the maintenance of adequate levels of circulating albumin in the face of reduced
synthesis. A failure of this adaptive process leads to a reduction in serum (albumin) proteins.
This reduction in intra-vascular oncotic pressure and outflow of water into the extra-vascular
space contribute to the development of edema seen in the kwashiorkor patient.
Hormones play a crucial role in the process just described above. They contribute to the
maintenance of energy homeostasis through increased glycolysis and lipolysis, increased
amino acid mobilization, preservation of visceral proteins through increased breakdown of
muscle proteins, decreased storage of glycogen fats and proteins and decreased energy
metabolism. Decreased food intake tends to reduce plasma glucose and free amino acid
concentrations that reduce insulin secretion and increase glucagon and epinephrine release.

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The stress induced by the low food intake also stimulates epinephrine release and
corticosteroid secretion. Some investigators have postulated that the evolution of PEM into
either kwashiorkor or marasmus may be partly related to differences in adrenocortical
response, whereby the better response will preserve visceral proteins more efficiently and
lead to the better-adapted syndrome of marasmus. Nevertheless, there is need for a gradual
adjustment to normalcy as a premature introduction of a high-calorie diet may be fatal to a
severely marasmic patient.
Severely underweight individuals are more likely to be ill, and their recovery from illness,
surgery or injury is apt to take longer than with normal persons. Indeed, infections that cause
the undernourished person to become acutely ill often have only a minor effect on the well
nourished. Diarrhea, which is the primary cause of death for under-five children in the less
developed countries, occurs much more frequently among the marasmic children than among
the well-fed and worsens the condition; the rapid passage of food material through the
intestine allows for limited absorption of nutrients. Researchers have demonstrated that work
capacity is lessened and physical strength and endurance is seriously lowered. Voluntary
exercise also decreased. Also, protein-energy malnutrition results in deficiencies that the
body is slow to restore, since it is limited by a total body protein turnover of approximately
4% per day. Restoration of body protein is particularly difficult due to the priority of energy
over protein requirements.
Obesity: The Nutritional “Disease of Affluence” In Developing Countries
Obesity, a pandemic disease of this century, is fast becoming one of the most important
public health problems in Nigeria, as a recent study shows that one out of every sixth Nigeria
may be carrying excess fat. Today, most people in the affluent world look upon obesity as
undesirable; and obesity is regarded as a form of malnutrition, which is most prevalent
among the lower socioeconomic groups, especially among women. In the poor countries,
however, the reverse is usually the case as obesity is least common among the lower
socioeconomic groups. Studies from Nigeria, so far, tend to support those from other parts of
the African sub-region and from other less affluent societies where the incidence of obesity
rises with an increasing degree of affluence. Among many Nigerian populations, until
relatively recently, being fat, as characterized by excess accumulation of body fat, was
considered an indication of affluence, beauty and health. Indeed, many Nigerians still view
fatness (obesity) without any concern, as it is often believed to add to the prestige of an
individual. But among the young educated Nigerians, especially among highly educated
women, however, obesity us fast becoming a health concern, if even it is for esthetic or
economic reasons. Women generally are much more sensitive to obesity than men are -
physical appearance is believed to be much more important to a woman than to a man.
Definition and Measurement of Obesity
Obesity, as characterized by an excess accumulation of body fat, has become a major health
concern of the modern man. When an individual’s energy intake consistently exceeds
expenditure, weight gain occurs and this ultimately results in obesity. In Western societies,
weight and body composition changes with age. In a normal adult male, subcutaneous fat is
about 11% of the body weight, while it is 18% for the adult female, with a gradual increase in
women from 20 to 60 and a more gradual increase for men from 20 to 50, with a fall
thereafter. A gradual accretion of fat and loss of lean body mass accompany these changes.

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 It is for this reason that the WHO classification for obesity has been found to be a practical
clinical tool. The method is based on two simple measurements: height, without shoes and
weight, with minimal clothing. This method is based on the weight/height, referred to as the
Body Mass Index (BMI). A BMI of between 25 and 29.9 is regarded as overweight, followed
by obesity grade I of a BMI of 30 to 34.5, grade II of 35 to 39.9 and grade III of over 40.
Normal adults have a BMI of 18.5 to 24.9. On account of the fact that being overweight is not
synonymous with being obese, it has become necessary to adopt the term, ‘desirable’ or
‘ideal’ weight, which is the weight that conforms to the longest life span. Since more than
half of the fat in the body is deposited under the skin, and its percentage increases with age,
triceps skin-fold thickness measurement has been proposed as a useful tool for measuring
obesity in adults. It has also been proposed that the figures of 23 mm and 30 mm for male and
female adults respectively as the minimum for defining the presence of obesity.
In general, an adult obese person is one (i) who, with the exception of the muscular athlete, is
9 kg or more above her desirable weight, (ii) who weighs 15-20% or more above her
desirable weight or weight attained at the age of 20, under normal nutritional considerations
(desirable weight being that which is compatible with optimum health and longevity), (iii)
whose triceps skin-fold thickness is 23 mm or more for men and 30 mm or more for women
at the age of 30 to 40, and (iv) whose BMI exceeds 29.9.
Causes of Obesity
Now it is important to understand the causes of obesity as these have serious implications for
its management. There are many reasons why people get fat. But the underlying factor is
ruled by the Law of Conservation of Energy, which states that energy can neither be created
nor destroyed but can be changed from one form to another. The excess energy that is
consumed gets stored as fat in the body, and can be likened to a savings account in which
more money goes into the account than comes out of it. The excess energy consumed by an
individual is stored in the tissues as potential energy in the form of fat. The causes of obesity,
which vary between individuals, may be due to one, two or more of the factors listed below.
These causes are broadly discussed under genetic, behavioral, physiological, and environ-
mental factors.
Although the evidence to determine the influence of heredity on obesity is inconclusive,
there are a number of investigations showing a high incidence of obesity among the parents
of the obese. Studies have provided circumstantial evidence to indicate that only 7% of the
children of normal weight parents are obese, whereas it is 40% when one parent is obese and
80% when both parents are obese. In other words, if neither parent is obese, your risk of
obesity may be less than 10%. But if you have one obese parent, the risk of fatness rises to
40%; and if both parents are obese, your chances of becoming so are some 80%. But the
impact of family food and food consumption patterns, which are taught by parents is thought
to have a great impact and cannot be excluded or overlooked, for this might be a reflection of
shared eating habits or activity patterns. In a study of 239 obese persons, 69% of them had
obese (one or both) parents. With adopted children, a lower correlation was observed
between the weight of the children and that of their parents than was observed between
natural children and their parents. Some studies, while showing a greater difference in twins
raised apart than in twins raised together, thereby implicating environment, also showed
greater weight difference than did identical twins, with remarkable tendency towards similar

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fatness or thinness, suggesting a strong genetic component and a significant contribution of
heredity to weight. The clear genetic effects of heredity are thus modified by environmental
and behavioral factors. Furthermore, the shape of the body helps to determine the total body
surface. A long, thin person will have much more body surface than will a short, plump
person of the same weight. And the greater the body surface, the greater the heat loss -
greater skin surface contributes to higher basal metabolism. It may also influence how many
calories of energy are lost during activity. Thus, nature tends to exaggerate the problems of
the heavy and perpetuate them. Ultimately, what is inherited "may result in different weights
in different circumstances, since it is a product of both nature and nurture".
A related factor in the development of obesity is the body type or somatotypes. In general,
there are three body types, namely, endomorphic (soft and roundish), mesomorphic (bony
and muscular) and ectomorphic (lean, linear, fragile, thin or slender, usually with long thin
fingers). The ectomorph has low fat storage capacity. The endomorph is almost an opposite.
He has much fat storage capacity. The mesomorph is more-or-less in-between. They are the
stocky, muscular, heavy-boned types. Pure body types are rare, however, and the
combinations are more common. Obesity is found more frequently among some body types
than others. Studies have shown that obese adolescents girls tend to be more endomorphic,
somewhat less mesomorphic but considerably less ectomorphic. But all these facts merely
show genetic predisposition. What ultimately determine obesity, as indicated earlier, is the
amount and or utilization of available food energy, especially when it is in excess of ‘normal'
needs.
Treatment and Prevention of Obesity
Since obesity is an important health concern for which modern medical profession provides
little or not effective cure, its best and most effective treatment is its prevention. Losing
weight and keeping off the weight is extremely difficult, especially for individuals who are
25% or more overweight. A gain of 2 kg above one's ideal body weight (see table below)
should be a signal to begin curtailing one's energy intake or increasing one's energy
expenditure. The mode of treatment varies from one individual to another; but it can include
diet and dietary advice, psychological counseling, exercise and drugs.
Vitamin Deficiency Diseases
When nutrient deficiencies were first noted, they were generally associated with vitamin
deficiencies. This is partly because vitamin deficiencies underlie numerous diseases, and also
because numerous diseases induce vitamin deficiencies. Today, nutritional diseases are
commonly associated with the excessive or deficient intake of some 55 different nutrients
needed by the human body. It is impractical that the deficiencies or excessive intake of all 55
known nutrients be discussed in just one course, lasting just a few weeks. However, an
attempt will be made to deal with only a few of the prominent ones commonly found in
Nigeria.
The following representative classical vitamin deficiency diseases, namely, the vitamin A
deficiency syndromes (Xerophthalmia/keratomalacia) and rickets or osteomalacia will now
be discussed together on account of their common occurrence in Nigeria. Before the
discovery of the vitamins and the subsequent elucidation of their roles in human nutrition
vitamin deficiency diseases were more prevalent in human populations than they are in
modern times. Thus, the complexity of their pathogenesis must be kept in mind when details

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of the disease syndromes are being discussed, since an understanding of the underlying
causes will make it possible for the public health worker to prevent their occurrence. For
example, chronic alcoholism, drug abuse or even the medically supervised use of drugs and
certain food fadism may lead to deficiency disease states.

Xerophthalmia/Keratomalacia
There is perhaps, no other nutritional disorder that has been studied in greater details than
that of vitamin A. Night blindness was a well-recognized disease in ancient Egypt. But the
credit for announcing the first vitamin (vitamin A) known to be essential to man goes to two
outstanding groups of investigators - Osborne and Mendel at Yale and McCollum and Davis
at the University of Wisconsin. The discoveries by these investigators in 1913 mark the
beginning of the modern nutritional history of vitamin A. Earlier in 1904, the disease had
been observed in children fed fat-free diets. Similar symptoms were observed in Danish
children who suffered from a lack of dairy products in their diets. Of the estimated 5 million
children who develop Xerophthalmia annually, approximately one-quarter of them become
blind within one year, and another half of the children die. Xerophthalmia seldom occurs in
isolation as it is often associated with marasmus and kwashiorkor. When the disease does not
accompany protein-energy malnutrition, its mortality rate is much reduced.
Under normal circumstances, the receptor cells or cones of the retina require constant
replenishment of the small amounts of vitamin A lost in the visual cycle during which a nerve
impulse is transmitted to the optical nerve and rhodopsin is regenerated. But when there is a
deficiency of vitamin A, it expresses itself in a progressive manner. First, the vitamin A-
deficient person experiences a history of night blindness (nyctalopia), which results from a
reduced concentration of rhodopsin (low serum vitamin A values) in the rod outer segments
of the eye, followed by a sequence of abnormalities of increasing severity in the conjunctiva
and cornea, termed Xerophthalmia. In Xerophthalmia, the protective secretions of the eye are
lost with consequent keratinization of the epithelial cells. The eyes become dry; the cornea
(the transparent outer covering of the eye) also becomes dry and loses its sensitivity. The
corneal involvement seems to arise from proteolytic destruction of collagen and other
structural proteins following leukocyte infiltration into the corneal stroma. Secondly, this is
followed by dryness (xerosis) of the bulbar conjunctiva. A further advancement of this
process is the development of Bitot’s spot, a heaping up of desquamated, keratinized
epithelial cells. The conjunctival changes, which include a loss of goblet cells and the
development of Bitot’s spots overlying keratinized epithelia, are likely caused by a reduced
concentration of retinol and of glycoproteins in tear fluid. A severe irreversible change in the
cornea, which ultimately perforates with loss of aqueous humor, is called keratomalacia. This
irreversible corneal involvement commences as a superficial punctate keratopathy, which
ultimately perforates the aqueous humor. It proceeds to varying degrees of ulceration and
liquefaction. Protein-energy malnutrition and zinc deficiency may also lower the rhodopsin
content of the eye, thus, exacerbating the condition. Viral infection such as measles also
exacerbates the process and subsequent bacterial infection complicates it.
Vitamin A deficiency also produces skin changes of extra-ocular manifestations including
perifollicular hyperkeratosis, a heaping up of hyperkeratinized skin epithelium around hair
follicles. Thus, vitamin A is necessary for the maintenance of the skin.
In the early days of the history of vitamin A, it was termed the “anti-infective” vitamin,

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based on the increased number of infections noted in vitamin A-deficient animals and
humans. In vitamin A deficiency, both specific and nonspecific protective mechanisms are
impaired, namely the humoral response to bacterial, parasitic and viral infections, cell-
mediated immunity, mucosal immunity, natural killer cell activity and phagocytosis.
Vitamin A is not a limiting nutrient in healthy individuals who eat an adequate mixed diet.
Good dietary sources of preformed vitamin A are liver and other internal organs, whole eggs,
dairy products and whole small fish. By far the richest sources of preformed vitamin A are
the liver oils of marine fish and of marine mammals. On the other hand, the good sources of
provitamin A (precursors) are carrots, dark green leafy vegetables, yams, spinach, tomatoes,
yellow maize, papayas, ripe mangoes and oranges. The richest sources of carotenoids are red
palm oil and carrot oil. Nutritionally, palm oil is preferable to most other vegetable oils found
in the Nigerian market.
Rickets/Osteomalacia
Francis Glisson was the first to describe the clinical manifestation of the bone disorder which
later came to be known as rickets. Children had been afflicted with rickets for centuries
before the relationship of the deforming disease to vitamin D or sunshine was understood. It
was a prevalent disease in England and other industrialized nations of the Northern
Hemisphere during the Industrial revolution. This was a time when there was slum crowding
in the cities and the smoke poured into the air to block the sun. In 1890, Palm observed that
the disease was rare where sunshine was abundant, and in 1919 Mellanby demonstrated that
rickets was a nutritional disease. In 1922, McCollum and coworkers discovered that cod liver
oil contained an antirachitic factor that he named vitamin D.
By current definitions, vitamin D can be viewed as both a vitamin and a hormone. Thus,
vitamin D supplementation is unnecessary for those who are able to meet their requirement
through the sunlight activation of 7-dehydrocholesterol in the skin. The resultant active
metabolite, 1, 25-dihydroxycholecalciferol, produced exclusively in the kidney and functions
in the intestines and bones, thus serves as a hormone. The most current nomenclature of the
active forms of the vitamin, namely vitamin D2 and D3 are respectively referred to as
ergocalciferol or ercalciol and cholecalciferol or calciol.
It has been demonstrated that vitamin D brings about normal bone and endochondral
calcification, preventing rickets in the young and osteomalacia in the adult. Thus, the
biochemical and physiological consequences of inadequate vitamin D intake results in rickets
in growing children and osteomalacia in adults. The ultimate effect of vitamin D is that the
vitamin D hormone alters the intestinal epithelial cells to permit Ca to enter the cell to be
transferred across and to be expelled in the serosal medium by a Na-dependent process.
Rickets occurs when newly synthesized organic matrix, osteoid, fails to mineralize, resulting
in soft bones. It shows a stricking failure of endochondrial calcification, which results in the
widening of the epiphyseal plate and the buildup of osteoid tissue, seen as bone deformities,
especially the bowing of the leg. In some instances, knock knees result instead of bowed legs.
Since the vitamin is essential for Ca absorption, it may also function in the prevention of
osteoporosis later in life. The usual background of such a person is a series of pregnancies
and periods of lactation, combined with a low intake of vitamin D intake and little exposure
to sunlight. The proof of the disease is that the defective absorption of calcium in the disease
is promptly corrected by vitamin D therapy. Usually, there is an extensive demineralization

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of the skeleton.
Mineral Deficiency Diseases
Nearly half of the world’s population lives in areas where there is significant iodine
deficiency. Its worst consequences are found in the developing fetus and child, leading to
death, complications of pregnancy and irreversible mental retardation. The knowledge of
endemic goiter, now known to result from iodine deficiency, goes back many centuries.
Although the association of endemic goiter with endemic cretinism had been recognized
since the 17th century, its relation to the thyroid gland was not known until the 19th century. It
was in the early 1920s that salt iodization was introduced.
Although early Egyptians used rust (iron oxide) to treat baldness, it was not until 1932 that
its role in human nutrition became established. Although iron constitutes only about 4 grams
in the entire body of a well-nourished adult, its significance in the physical well-being of an
individual cannot be over-emphasized. Iron is one of the most important elements in human
nutrition, as it is of fundamental importance to life. However, its role in nutrition is almost
exclusively confined to its role in oxygen transport and cellular respiration.
Goiter
Although the Chinese had used seaweed as a remedy for goiter for centuries, iodine was not
used for the treatment of goiter until 1816. Similarly, even though Courtois had discovered
the element in 1811, during the course of making gunpowder, it was not until 1895 that
Baumann discovered it in the thyroid gland in 1895. A landmark event in the history of this
mineral was demonstrated in 1917 by Marine and Kimball when they showed that endemic
goiter could be prevented by administration of small amounts of iodine to children at risk.
They later demonstrated that goiter resulted from iodine deficiency. Subsequently, mass
prophylaxis of goiter with iodized salt was first introduced in Switzerland and in Michigan.
When goiter is due to the lack of iodine, it is termed simple, endemic or euthyroid goiter.
This disease is more common in women than in men and is often noticed at the onset of
puberty, during pregnancy, or at the menopause. In the developing countries of the world,
more than one billion persons are said to be at risk of iodine deficiency disorders. In these
places, some 220 million people suffer from goiter, and more than 5 million are suffering
from mental retardation as gross cretins, and 15 to 25 million suffer from lesser mental
defects.
Most of the iodine found in nature resides in the sea and ocean. Glaciation, snow, or rain,
having been washed down from the hilly regions of the world brought it there. Thus, iodine
deficiency is likely to occur in all elevated regions subject to glaciation, high rainfall and
runoff. Iodine occurs in soil and the sea as iodide. Iodine ions are oxidized by sunlight to
elemental iodine, which is volatile. Annually, some 400,000 tons of iodine escape from the
surface of the sea. Happily, some of this is returned to the soil by rainfall, but it does not
compensate for the loss. Consequently, primary iodine deficiency persists in the soil
indefinitely, and all crops grown in such soils are iodine-deficient. This may explain why
goiter is found mainly in the hilly regions of Nigeria. Where food supply comes from crops
grown on iodine-deficient land, supplement will have to be provided or the diet diversified to
allow for sea foods.
The regulation of the thyroid hormones is a complex process involving several organs,
including the thyroid, the pituitary, the brain and the peripheral tissues. Consequently, when

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goiter is severe, it is often accompanied by cretinism. In recent years, it has become evident
that maternal iodine deficiency is an important cause of fetal growth retardation, which
particularly affect the development of the brain.
The thyroid gland, which weighs only about 15 to 25 g, contains about 70 to 80% of the total
iodine in the body, thus possessing a remarkable concentrating power for iodine. However,
the normal intake and requirement for the mineral is about 100 to 150 micrograms. Within
the thyroid gland, it exists as inorganic iodine. Its functional forms are the iodine-containing
amino acids, monoiodothyronine (MIT), diiodo-thyronine (DIT) and as polypeptides
containing thyroxine. The thyroid gland has to trap about 60 micrograms of iodine per day in
order to maintain an adequate supply of thyroxine. The active transport mechanism by which
this happens is what is called the ’’iodine pump,” and is regulated by the thyroid-stimulating
hormone.
In communities where improperly processed cassava is consumed, goitrogens such as
thiocyanate - a derivative of hydrogen cyanide found in cassava - may compete with iodide,
thus rendering the iodine unavailable. Where there is a congenital defect in biosynthesis of
MIT and DIT, it might result in a congenital form of goiter and hypothyroidism, which may
run in families. However, congenital goiter does not occur in iodine-deficient goiter. Where
goiter is due primary to iodine deficiency, the term, iodine deficiency disorder (IDD) has
been used to describe the effects of the deficiency. Indeed, iodine deficiency is indicated in
any community when the 8-14 year-olds are shown to have goiter.
The Food and Nutrition Board (1989) has recommended that a daily iodine intake of 40
micrograms for children aged 0 to 6 months, 50 micrograms for those between 6 months and
1 year, 70 to 120 micro-grams for 1 to 10 year-olds and 120 to 150 micrograms for 11 year-
olds and beyond. The recommended rates during pregnancy and lactation, respectively, are
175 to 200 micrograms. These amounts are usually supplied by increasing the amount of sea
foods consumed in the community and by the use of iodized salt and injectable iodized oil.
Currently, an International Council for the Control of Iodine Deficiency Disorders (ICCIDD)
is being coordinated by the WHO and UNICEF.
Iron-Deficiency Anaemia
Anaemia is a decrease in the total red cell mass due to fewer red blood cells or to smaller red
blood cells which contain less hemoglobin. There are three forms of nutritional anemia,
depending on the nutritional factor(s) involved in their causation. These factors include iron,
folic acid and vitamin B12, the deficiencies of which respectively, cause iron deficiency
anemia, folic acid deficiency anemia and pernicious anaemia. The commonest of them is iron
deficiency anemia. This review will be dealing with only the latter since it is, by far, the
commonest of them all. Furthermore, iron deficiency is a systemic disorder in which
symptoms do not arise from the anemia alone, but may occur in the absence of an anemia.
The infantile form of hypochromic iron-deficiency anemia occurs during infancy all over the
world. Unfortunately, anaemias, especially, iron-deficiency anemia, constitute an important
problem that has received less attention than it deserves, possibly because of its relatively
undramatic clinical picture. Indeed, iron deficiency is the most common nutrient deficiency
and may well be the most common organic/nutritional disease of man. Hypochromia and
microcytosis of the red blood cells characterize severe iron deficiency anemia.
Iron deficiency results from one or a combination of the following inadequate diet, impaired

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absorption, blood loss or repeated pregnancies. However, iron-poor diet is very rarely the
primary cause of iron deficiency in adults. This is because the normal excretory loss of iron is
so small that once a person has attained adulthood with normal body iron stores, a subsequent
iron-poor diet and poor iron absorption deplete iron reserves and lead to anemia only after
many years. Spoon-shaped nails (koilonychia) are characteristic of long-standing iron
deficiency. Even mild degrees of iron deficiency are considered to be an important factor in
decreased work efficiency.
Iron, as a metal, is one of the most useful in technology and biology as they are involved in
numerous oxidation-reduction reactions. Aerobic metabolism is dependent on iron because of
its role in the functional groups of most of the enzymes of the Krebs cycle and as an electron
carrier in cytochromes. Iron-deficiency anemia is most prevalent during pregnancy. This is
because the requirements during pregnancy are frequently so large that they are greater than
the amount available from diet alone thus necessitating supplemental therapy, especially in
the last trimester. During the last trimester of pregnancy, 3 to 4 mg of iron are transferred to
the fetus each day. The fetus has a highly effective acceptor system for assimilating iron.
Normally, iron from maternal transferrin is moved to the placental tissue, to the fetal plasma
transferrin, from where it is transferred to the placental tissue in a unidirectional pathway that
operates against increased maternal requirement for iron, even when there is maternal iron
deficiency. In areas where intestinal heminthiasis, especially hookworm disease, exists in a
large proportion, iron deficiency anemia is nearly universal. The only way by which
significant amounts of iron leave the body after absorption into the bloodstream is through
loss of blood due to the admirable blood donations, abnormal hemorrhage from accidents or
illness and menstruation. Thus, the development of iron deficiency in an adult man or post
menopausal women should be assumed to be due to blood loss until proved otherwise.
Indeed, the two most common causes of iron deficiency among adults are increased
menstrual bleeding and hemorrhage from the alimentary tract. Many healthy women have
virtually no iron reserves. The women who consider their menses normal may lose more than
100 ml and occasionally more than 200 ml per period. IU devices, which increase menstrual
bleeding, influence these losses, and by contraceptive pills, which decrease it. Hallberg and
coworkers reported that the mean menstrual loss of iron amounts to about 0.5 mg per day. A
good indicator of iron store in a healthy person is the concentration of ferritin. A useful rule
of thumb is that 1 ml of packed red cells contains 1 mg of iron. Therefore, a chronic loss of
even a small volume of blood may significantly increase iron requirements, and for those
who donate blood, each 500 ml of donated blood contains 200-250 mg of iron.
A healthy person can only absorb about 5 to 10% of dietary iron, and those who are iron-
deficient absorb about 10 to 20%. Since maize is poor in iron, and also contains phytates that
chelate iron, further reducing iron availability, iron deficiency anemia is quite common
among cereal- (maize)-eating populations. Furthermore, geophagia, which interferes with
iron absorption, is common among children and adult women. The ingested clay chelates or
precipitates iron as insoluble compounds. Among the poor, clay-eating is more common than
generally realized. This is particularly true when animal protein intake is low. However,
women often fail to recognize an abnormal blood flow, even when double pads must be worn
because one soaks through or duration of periods is greater than 5 days, or large clots are
passed, or more than 12 pads are needed per period. Also, the admirable and necessary

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donation of large amounts of blood is a form of hemorrhage.
Iron is absorbed in two forms: heme and non-heme forms. However, the major source of iron
for the greater percentage of the population is nonheme iron, and a means of enhancing its
absorption is a necessity for combating iron deficiency anemia. These factors are capable of
initiating or perpetuating iron deficiency anemia. Heme iron found in fish, meat and poultry
is highly available and not affected by the composition of the diet, whereas the nonheme
forms found in cereals and vegetables are less available and is influenced by the dietary
composition. Actually, meats improve the absorption of nonheme iron, while dairy products
(egg, milk and cheese) do not. On the other hand, vit.C increases the absorption of non-heme
iron by reducing the ferric form to the more soluble and better absorbed ferrous form.
Furthermore, two foods, bran and tea, interfere with iron absorption owing, respectively, to
their fiber and phytate components. Drinking tannin-containing beverages, such as tea with
meals that consist largely of vegetable foods causes a decrease in iron absorption. In contrast
to the very poor absorption of iron from such foods as wheat germ, spinach, on account of
their phytate content, iron absorption is moderately good in carrots, tomatoes, cabbage which
contain substantial amounts of malic, citric or ascorbic acids. Exogenous iron is significant in
the iron-rich diets of many African peoples. The iron is derived from iron pots used for
cooking and for the preparation of fermented beverages. Other studies have shown that iron
utensils contribute significantly to the iron content of cooked foods. Thus, the substitution of
aluminum, stainless steel or plastic-coated pots and pans has certainly had an adverse effect
on dietary iron intake.
Both the intake and uptake of iron can affect iron status. Fortuitously, blood loss through
hemorrhage or blood donation increases erythropoiesis and absorption. The absorption
depends on mucosal uptake of dietary iron by the intestinal absorptive cells and the transfer
of the same into the body. This further depends on ample supply being exposed for sufficient
interval of time for the action to take place. Thus, the iron must be in a physiochemical form
that permits absorption to the extent of the body’s requirement. Thus, the knowledge of the
iron content of a diet may be a relatively poor indicator of nutritional adequacy or
inadequacy.
Unlike most nutrients, iron excretion is limited, as its control rests on its absorption. Once
iron enters the bloodstream, it tends to be used and reused. Indeed, more than 90% of
hemoglobin iron is repeatedly recycled through the process of phagocytosis of old
erythrocytes, whereby some 19 to 69% reincorporation occurs within 12 days. The remaining
iron derived from hemoglobin catabolism enters the storage as ferritin or hemosiderin. Iron is
stored chiefly in the liver, spleen and bone marrow. Only about 0.3 to 0.5 mg of iron is
excreted daily in the feces, which comes from blood loss into the intestine and desquamated
intestinal mucosal cells and from an unabsorbed food iron.

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 Excessive Intake Vitamins and Minerals
The belief by many uninformed persons that if “a little is good: a lot is better” has led to the
excessive intake of several important nutrients. In this discussion, however, we shall concentrate
on just three of such nutrients, namely, vitamin A, vitamin C and iron. What is clear, however, is
that there is hardly any nutrient that cannot be abused or overused.
Hypervitaminosis A and Hypercarotenosis
It is well known that vitamin A is an essential nutrient required for the maintenance healthy
epithelial tissue, for growth and for vision. On the other hand, there is no nutritional advantage to
be derived from exceeding the recommended level of vitamin A. The intolerable upper limit of
preformed vitamin A rises from 600 micrograms per day for infants to 2,800 for adolescents up
to 3,000 for adults. The most usual cause of hypervitaminosis A are prolonged consumption of
vitamin A-containing supplements, in the belief that “a little is good: a lot is better”.
Furthermore, the physical form of retinol supplements is a major determinant of toxicity: water-
miscible, emulsified and solid preparations of retinol are approximately ten times more toxic
than oil-based retinol preparations. Unfortunately, some vitamin preparations do contain as many
as 25,000 IU of vitamin A. Although the level at which vitamin A becomes toxic varies from one
individual to another, a daily dose of 50,000 I.U. for many months can induce toxic symptoms in
adults. When taken over an extended period of time, this could be dangerous, especially during
pregnancy, producing teratogenic effects in the fetus.
Symptoms often include anorexia, irritability, loss of weight, sparseness of hair. A single dose of
a million units of vitamin A can cause severe, acute toxicity. Persons have been known to die
from eating large amounts of polar bear liver. Acute manifestations include transient
hydrocephalus and vomiting. Chronic hypervitaminosis A has also been observed in infants 3 to
6 months of age. Chronic hypervitaminosis A in children usually results from overzealous
parents who are uninformed or believe that high doses will provide beneficial results. A skin
disorder, such as acne, for which a remedy is sought, may be a result of excessive dosage of
vitamin A. In adults, chronic hypervitaminosis A has been observed in patients receiving large
doses (20-30 times RDA) as a treatment for a dermatologic condition. Thus, hypervitaminosis A
can be avoided by obtaining vitamin A only from dietary sources or low potency preparations.
The only therapy is to stop the administration of the vitamin or such other drug containing it. If it
is necessary to take vitamin A supplements, the vitamin A content of the supplement should
approximate the Recommended Dietary Allowance.
Excessive intake of carotenoids can cause hypercarotenosis - yellow or orange discolor-ation of
the skin. Some persons do consume unusually large amounts of provitamin A sources, such as
the carotenoids but the inefficiency of the conversion of provitamin A to pure vitamin A virtually
eliminates the possibility of hypervitaminosis A. The resultant accumulation of the provitamin A
pigment causes the yellowing of the skin and the other epithelial layers of the body.
Hypercarotenemia has also been documented where there has been prolonged ingestion of large
amounts of carrot juice. Where hypercarotenemia has been due to dietary origin, symptoms
disappear within a few weeks after withdrawal of the cause.
Hypervitaminosis C
 A book, Vitamin C and the Common Cold, by Linus Pauling, a two-time Nobel Prize winning
scientist, extolled the virtues of large doses of vitamin C in preventing and treating the common
cold. He recommended the astronomical doses of 10,000 to 15,000 milligrams per day, in
comparison with the 45 mg per day recommendation of the American National Research
Council. Although Pauling’s theory has captured public interest, there have been several
reasonably well-documented studies that have not substantiated his theory.
It has been suggested that vitamin C plays a role in cholesterol metabolism. Some studies have
shown that when large doses of vitamin C were given to hypercholesterolemic subjects, their
serum cholesterol levels were decreased. The claim has also been made that doses larger than the
RDA could be advantageous in treating respiratory ailments. However, the ingestion of large
amounts of vitamin C is not without toxic effects. Reports have indicated that the resultant acid
urines may contribute to the formation of renal calculi in those with tendency to gout
Furthermore; ascorbic acid is metabolized through the formation of oxalic acid, a substance that
also contributes to the production of renal calculi. Thus, chronic intake of vitamin C in excess of
the adult tolerable upper limit of 2,000 mg per day can cause diarrhea, kidney stones and excess
iron absorption.
While massive doses of vitamin C might reduce the severity of upper respiratory infections in
individuals whose tissues are not fully saturated with the vitamin, levels above those necessary
for tissue saturation could be harmful, as respiratory infections could increase the amount of
vitamin C required for tissue saturation.
Hemosiderosis
There is no evidence that high iron intake, by itself, can lead to secondary iron overload. But
excessive dietary iron intake can be detrimental to health, under certain circumstances. The
storage form of iron, ferritin, is normally found in the intestine, liver, spleen and bone marrow. If
iron is taken into the body parenterally, in amounts exceeding the capacity of the body to store
ferritin, it accumulates in the liver as microscopically visible hemosiderin. Furthermore, in
certain parts of Africa, traditional fermented beer from maize has been shown to be contaminated
by the iron-containing brewing vessels, causing hemosiderosis. Acute iron poisoning causes
vomiting, upper abdominal pain, diarrhea, drowsiness and shock. Death may occur in children
who mistake iron tablets for sweets. In chronic iron toxicity (hemochromatosis or iron load)
affects many organs and tissues. Eventually, diabetes often results in 80% of such patients. The
liver becomes enlarged and cirrhotic, and hepatocellular cancer may develop. Cardiomyopathy
may also develop, causing heart failure. Mental aberrations and pituitary failure may cause
testicular atrophy and loss of libido. Focal hemosiderosis can damage lungs and kidneys.
Sub-Saharan hemochromatosis appears to have a genetic basis, but it is usually associated with
long-term diets high in iron derived from cooking pots or steel barrels used in preparing
fermented alcoholic beverages. In such patients, portal cirrhosis and diabetes are common.
However, despite associations of high serum ferritin with heart disease, type-2 diabetes, and
colon cancer, adverse health effects of moderately elevated iron stores in the general population
should be viewed with caution.
 Formulation of Weaning And Therapeutic Diets
A discussion on the foundations of a healthy diet must begin with information regarding food
choices. Until recently, the primary focus of human nutrition had been the prevention of
nutritional deficiencies as well as achieving the RDA (Recommended Dietary Allowance) for the
different nutrients. In recent times, however, the definition of a healthy diet has been expanded to
include the optimization of long-term health. The motivative force for this expansion has been
the epidemiologic evidence that coronary heart disease (CHD) and cancer are major killers in the
world. Thus a consideration of a healthy diet must include macronutrient composition,
qualitative aspects of macronutrient such as glycemic index, food constituents such as fiber and
carotenoids and the possible benefits of nutrients at intakes higher than those known to prevent
deficiencies.
Principles of Dietetics
An understanding of nutrition is important since a health worker is often required to help others
whose eating habits require improvement. For example, certain patients, under medical care,
require diet therapy and the consumption of prescribed foods in specified amounts. Furthermore,
patients often have questions and complaints about a group of prescribed foods (diet) which are
new to them. This could assume the following dimensions: (a) changing a nutritionally
inadequate diet to a nutritionally adequate one and adding a subtracting certain nutrients of foods
in specified amounts to or from a diet. Such diets are called therapeutic diets.
Since it is difficult to get patients to eat unfamiliar meals, based on the therapeutic diet, special
efforts, which require special skill, should be made by the person serving the food to encourage
or motivate the patient to overcome prejudices and eat the food being served., Unless prescribed
foods are eaten, any diet is useless and a beautifully designed diet that is not consumed serves no
purpose. Often the physician may be surprised that a patient is not sticking to his diet. Thus,
having this basic understanding of the special skill of the dietitian is an important
interrelationship between the physician and the other health workers, who are looking after the
patient. When a patient dislikes a desirable food item, such item could be included in a disguised
fashion when combined with other foods. For example, milk could be included in the more
acceptable ice-cream or in custard.
Moreover, since most people have better appetites when they are rested, it is advisable to serve
the most nutritious meals early in the day, while making the evening meals light.
Adequate nutrition is necessary for building and maintaining good health during and after an
illness. Using nutrition to build good health is called diet therapy, which is a means by which the
normal diet of a patient is modified or changed in order to meet his current requirements created
by disease or injury. Describing an optimal diet is not as simple as it appears. For example, an
African soup can be as varied as possible, depending on the type of vegetables used and the
mode of preparation (cooking, frying which can destroy certain nutrients, etc.). Also, since
excessive body fat, resulting from an imbalance between energy intake and expenditure, is one of
the most important nutritional problems of the world, a definition of a healthy diet that fails to
address this problem would be incomplete or deficient. Furthermore, the consumption of the
healthiest combination of foods, consumed in slight excess, over an extended period will lead to
weight problems. The problem is further compounded by the highly imprecise estimation of the
quantities of foods, as serving sizes vary greatly. Therefore, a definition of a healthy diet needs
to be linked with the importance of maintaining a healthy weight and the need to make
adjustments in intake or physical activity if am imbalance exists.
Obesity, which is a state of having excess body fat, has become the most important nutritional
problem in the developed countries and is rapidly becoming a global epidemic and a definition of
a healthy diet should address this pandemic problem. However, a fundamental problem of
addressing this issue is that even the healthiest combination of foods consumed in slightly excess
by only a percentage or two, over an extended period will lead to over-weight.
In general, individuals differ in their response to nutrient intakes. For example, response of
serum cholesterol to dietary cholesterol or of blood pressure to sodium intake varies greatly. The
elucidation of the human genome and rapid identification of polymorphisms in almost all genes
is creating new opportunities to individualized dietary guidance. Thus, the ability to identify
individual persons with different requirements allows more detailed studies to ensure that their
needs are being met.
Application of these Principles of Management of Diabetes
The objectives of a diabetic diet therapy include (a) the provision of nutritionally adequate diet;
(b) the prevention of excessive postprandial hyperglycemia; (c) the prevention of hypoglycemia
in the insulin-dependent patients; (d) the attainment and maintenance of ideal body weight; (e)
the control of blood lipids and (f) the prevention or hindrance in development of pathologic
changes associated with diabetes. Developing a prescription that is reasonably consistent with
the patient’s preferences and situation can greatly increase the likelihood that it will be regularly
followed. Even if the prescription is slightly sub-optimal, if well followed, it usually is preferable
to a theoretically ideal prescription that is unattractive or unfeasible and will not be followed.
Furthermore, since there is a much stronger relation between greater body mass index and insulin
resistance, a person who is lean and active can better tolerate a high carbohydrate diet than one
who is less active and over.