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Nutrition Reference Man

Nutrition Reference man

He is between 18-29 years of age and weighs 60 kg with a height of 1.73m with a BMI of 20.3 and is free from disease and physically fit for active work; on each working day, he is engaged in 8 hours of occupation which usually involves moderate activity, while when not at work he spends 8 hours in bed, 4-6 hours in sitting and moving about, 2 hours in walking and in active recreation or household duties.

Reference Woman

She is between 18-29 years of age, non-pregnant non- lactating (NPNL) and weighs 55 kg with a height of 1.61m and a BMI of 21.2, is free from disease and physically fit for active work; on each working day she is engaged in 8 hours of occupation which usually involves moderate activity, while when not at work she spends 8 hours in bed, 4-6 hours in sitting and moving about, 2 hours in walking and in active recreation or household duties. Age group/ Category Caloric Protein Sex Requirement requirement (Kcal/day) Man Sedentary 2320 1 gm/kg/day Moderate 2730 Heavy 3490 Woman Sedentary 1900 1gm/kg/day Moderate 2230 Heavy 2850 +350 +0.5 gm (1st trimester) +7 gm (2nd trimester) + 23 gm (3rd trimester) Lactation +600 +19 gm (0-6 months)

Lactation +520 +13 gm (7-12 months) Recommended metabolizable energy

Protein 4 Kcal/gm Fat 9 Kcal/gm Carbohydrates 4 Kcal/gm Dietary Fiber 2 Kcal/gm 7 Kcal/gm Healthy

• Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice). • At least 400 g (5 portions) of fruits and vegetables a day. • Less than 10% of total energy intake from free sugars, but ideally less than 5% of total energy intake for additional health benefits. • Less than 30% of total energy intake from fats. Unsaturated fats are preferable to saturated fats. Industrial trans fats are not part of a healthy diet. • Less than 5 g of salt per day and use iodized salt. Assessment of protein quality

Amino acid score = No. of mg. of one amino acid per gram of protein X 100 No. of mg. of same amino acid per gram of egg protein

Digestibility coefficient= absorbed X 100 Nitrogen intake

Assessment of protein quality

Biological value = nitrogen retained X100 Nitrogen absorbed

Net protein utilization = nitrogen retained X 100 Nitrogen intake Assessment of protein quantity

Protein efficiency ratio = weight gain in gm Protein intake in gm MCQ The highest percentage of monounsaturated fatty acids is present in- a) Sunflower Oil b) Mustard Oil c) Rice bran Oil d) Olive Oil

The net protein utilization is defined as- a) The gain in weight of young animals per unit weight of protein consumed b) The product of digestibility coefficient and biological value c) The percentage of protein absorbed into the blood d) The percentage of nitrogen absorbed from the protein absorbed from the diet

A teacher will be classified as a a) Sedentary worker b) Moderate worker c) Heavy worker d) Average worker A ‘safety margin’ of + 2 SD is not incorporated for the RDA of a) Energy b) Fats c) Water soluble d) Fat soluble vitamins For a 60 kg Indian male, the minimum daily protein requirement has been calculated to be 40 g (mean) & standard deviation is 10. The recommended daily allowance of protein would be: a) 60 g/day b) 70 g/day c) 40 g/day d) 50 g/day The assessment of protein quality is done by all except- a) Protein efficiency ratio b) Biological value c) Digestibility coefficient d) Net protein utilization Egg is deficient in a) Carbohydrates b) C c) Both of the above d) None of the above The extra energy allowance needed per day during pregnancy is- a) 150 Kcals b) 200 Kcals c) 350 Kcals d) 550 Kcals An average sized egg would provide (UPSC CMS 2012) a) 50 kcal b) 70 kcal c) 90 kcal d) 110 kcal Vitamins

Functions: 1) It is vital for the formation of pigment rhodopsin in rods of the retina 2) integrity of cellular structure 3) immune defense mechanism of the body 4) antioxidant property

RDA: • 2000 IU / 600 µg RE • Pregnant & Lactating mothers- 950 RE

Vitamin A

Sources: • Richest source is Halibut oil followed by . • Top sources of vitamin A include: • Beef liver • Egg yolk • Cheddar cheese • Fortified milk

Xerophthalmia

Night blindness Conjunctival xerosis Bitot’s spots Corneal xerosis Corneal ulceration Corneal scar Xerophthalmic fundus Treatment

<6 months 50,000 IU 6m- 1 year 1 lac IU >1 year but weight less than 8 kg > 1 year 2 lac IU

The above dose should be given on Day 0,1 and 14 Vitamin A Supplementation

The first dose of 100,000 IU is given at 9 months of age along with measles vaccines. Thereafter, the second and subsequent doses of 200,000 IU are given at 6 monthly intervals till 5 years of age.

Thiamine (B1)

Functions: • Acts as a coenzyme in many metabolic reactions • health of the nerve tissue and for normal cardiac and gastro-intestinal functions

RDA: • 0.5mg per 1000 Kcal

Sources: Yeast, egg yolk, liver, wheat-germ, nuts, red meat and cereals

Deficiency: Beriberi and Wernicke- Korsakoff psychosis

Wet beriberi is the acute form - CVS Dry beriberi is the chronic form of disease - PNS Infantile beriberi occurs in the first few months of life Wernicke-Korsakoff psychosis (wet brain, alcoholic encephalopathy)is seen in • chronic alcoholics with poor diet • in patients undergoing prolonged intravenous therapy without B1, • gastric stapling • hunger strikes.

Treatment

Beriberi - Thiamine 500 mg in 10 divided doses Wernicke-Korsakoff psychosis – Thiamine 1000 mg in 10 divided doses (B2) Sources: Dairy products, liver, vegetables, eggs, cereals, fruit, yeast

Functions: (a) Promotion of normal growth (b) Assisting synthesis of steroids, RBC and glycogen (c) Maintenance of mucous membranes, eyes and the (d) Aiding iron absorption

Riboflavin (B2)

RDA: • 0.6 mg per 1000 Kcal Deficiency: • Cheilosis, angular stomatitis, glossitis, magenta tongue, nasolabial seborrhea and genital (scrotal or vulval) dermatosis

Niacin (B3)

Sources: • Meat (especially the organs), fish, chicken, eggs, milk, whole meal cereals, groundnuts and pulses are good sources. • 60 mg of tryptophan is needed to form 1mg niacin

RDA: • 6.6mg niacin equivalents per 1000 Kcal

Functions: As coenzymes in metabolism

Deficiency: (a) Dermatitis: The neck is frequently involved and the distinctive distribution of skin lesions is known as Casal’s Collar. (b) Diarrhea: This is often accompanied by inflamed scarlet tongue. (c) Dementia: It may present as mild confusion and disorientation to mania and psychosis.

Pyridoxine (B6)

Functions: Metabolism of amino acids, fats and carbohydrates RDA: 2mg; Pregnancy and lactation- 2.5 mg Sources: Milk, liver, meat, egg yolk, fish, cereals, legumes and vegetables. Deficiency: Peripheral neuritis

Cyanocobalamin (B12)

Functions: (a) Vitamin B12 plays important role in the synthesis of DNA (b) It helps in maintenance of myelin in the nervous system (c) It has an important role in the treatment of pernicious anemia

RDA: 1 μg

Sources: • not present in any vegetable foods. • present in animal products - milk, milk products, meat and fish. • also synthesized by the microorganisms in the gut

Deficiency: • Megaloblastic anemia • Peripheral neuropathy Folic Acid

Functions: (a) synthesis of DNA. (b) anti anemia factor

RDA: • 100 µg • Pregnancy 400 µg • Lactation 150 µg

Sources: It occurs in green leaves, pulse, cereals, liver, , mushroom and yeast

Deficiency: • Megaloblastic anemia • Neural tube defects • Hyperhomocystenemia Vitamin C

Functions: • formation of collagen • enhances the absorption of iron • anti-oxidant property

RDA: • 40 mg • 80 mg for lactating women

Sources: • Gooseberry (Amla) is the richest source. • Citrus fruits • Liver, whale skin, oysters, brain are good animal sources

Deficiency: •

Vitamin D Functions: absorption and excretion of ; bone mineralization

RDA: 100 IU Sources: Cod liver oil, other oily fish, milk, margarine, eggs, liver.

Deficiency: • in Children • in adults

Stoss therapy for treatment of Rickets

• Give 600,000 IU of Vitamin D2 orally • White line of deposition at the growing ends of bones • If it fails, then repeat • If no improvement still, then it’s Vitamin-D resistant rickets. • calcium 1000 mg/day

• After 3-months, maintenance dose - 400 IU of Vitamin D2

Vitamin K

Functions: Synthesis of Prothrombin and blood coagulation factors.

RDA: 0.03 mg/kg/day

Sources: Exogenous: Green leafy vegetables, vegetable oils esp. soya bean oil, eggs, meat and dairy products Endogenous: Gut bacteria

Deficiency

• Deficiency Bleeding (VKDB)

• All newborns with birth weight of 1000gm or more should be administered 1mg of Vitamin K IM while those weighing less than 1000 gm should receive 0.5 mg dose.

Daily requirement of Thiamine is determined by metabolism of which of the following (AIIMS 2009) a) Proteins b) Fats c) Carbohydrates d) Cholesterol

Prolonged treatment with Isoniazid leads to deficiency of- (AIPGME 2011) a) Pyridoxine b) Thiamine c) Pantothenic acid d) Niacin All of the following are true except (AIIMS 2009) a) Vitamin K is given in Keratomalacia b) A causes Pseudotumor cerebri c) Zinc excess causes pulmonary fibrosis d) causes Goiter When a patient is cut off the sources of vitamin A its deficiency is manifested after (AIIMS 2008) a) 1 year b) Immediately c) Within weeks d) Within few days Which of the following vitamins given as a supplement during the peri-conceptional period to a woman can help prevent the neural tube defects in the baby? (UPSC CMS 2012) a) Thiamine b) Riboflavin c) Vitamin B12 d) Folic acid Earliest feature of is: a) Conjunctival xerosis b) Nyctalopia c) Bitot’s spots d) Keratomalacia Which of the following is not known to have an antioxidant effect? a) Vitamin A b) L-Ascorbic acid c) Alpha-Tocopherol d) Phylloquinone Which of these is available only from animal sources? a) Vitamin B12 b) Vitamin B1 c) d) Vitamin B2 The richest source of Vitamin A is a) Halibut Liver Oil b) Cod Liver Oil c) Shark liver Oil d) Cheddar Cheese For assessment of Xerophthalmia as a public health problem, the age group of children is- a) 0-60 months b) 0-72 months c) 6-60 months d) 6-72 months Casal’s Collar is seen in deficiency of a) Pyridoxine b) Niacin c) d) Riboflavin Minerals Calcium Sources: • Milk and milk products, ragi, fish (if eaten whole), dried fruits such as raisins, apricots and dates, and betel leaves with lime, pulses and tofu

Functions: • providing the structural rigidity to bones and teeth. • maintenance of optimum excitability of the nervous and muscular tissues. • role in the coagulation of blood as factor IV • co-factor for a number of enzymes e.g. lipase

RDA of calcium Mg/day Men 600 Women 600 Pregnancy 1200 Lactation 1200 Post-menopausal women 800 Infants 500 Children (1-9 years) 600 Children and adolescents (10-18 years) 800 Deficiency

Tetany- twitching of muscles of face, hand and feet, cardiac arrhythmias

Sources: Milk and milk products, cereals, meat, fish, nuts, fruits and vegetables

Functions: • Formation of bones and teeth along with calcium. • role in all metabolisms • buffer that prevents changes in the pH of body fluids. • constituent of nucleic acids, phospholipids and membranes

RDA: 1 gm

Deficiency: Unlikely

Sodium

Sources: • Salts, MSG, meat, milk, eggs, vegetables and fruits • Preserved foods and canned foods

Functions: • blood pressure regulation along with potassium. • Acid-base regulation • maintains the osmotic pressure. RDA: 5 gm of sodium chloride (2 gm of sodium)

Deficiency: • Muscle cramps and severe dehydration and hypovolemia.

Excess: • High intake of salt (sodium chloride) is associated with high blood pressure and stomach cancer.

Potassium

Sources: • Fruits like melons, apricots, fruit juices, vegetables including potatoes, pulses, meat and whole grain cereals.

Functions: • Regulation of osmotic pressure • Acid base regulation • Release of insulin by pancreatic cells

RDA: • 4.7 gm

Deficiency: • Cardiac arrhythmias and muscle weakness Iron Sources: • Haem iron sources: Meat, fish and eggs. • Non-haem iron: Cereals, dark green leafy vegetables, pulses, nuts and dry fruits

Functions: • component of haemoglobin and myoglobin. • constituent of important enzymes RDA

RDA of Iron Mg/day Man 17 Woman 21 Pregnancy 35 Lactation 25 Deficiency: anemia

Confirmed case: • A case of pallor with or without associated weakness, tiredness and breathlessness at rest with hemoglobin and/or hematocrit levels less than normal

Group Hemoglobin threshold Hematocrit (g/dl) threshold (l/l)

Children 6 - 59 11 0.33 months Children 5 - 11 years 11.5 0.34 Children 12- 14 years 12 0.36 Pregnant women 11 0.36 Non- pregnant 12 0.33 women Men 13 0.39 Treatment of mild anemia

Children 1-5 years 20 mg Iron and 100 mcg Folic acid Children 6-11 years 40 mg Iron and 200 mcg folic acid Adolescents and adults 60 mg Iron

Pregnant women 100 mg iron and 500 mcg Folic acid Iodine

Sources: • and vegetables grown on iodine-rich soils • Dairy products, eggs, cereal grains, legumes and green leaves (spinach)

• Functions: • Component of thyroid hormones

RDA

RDA of Iodine µgm/day

Infants 90

Young children (1-5 years) 90

School age children (6-11 120 years) Adolescents and adults (> 12 150 years) Pregnant and lactating women 250 NIDDCP

• Process indicators: Indicators to monitor and evaluate the salt iodization process

Under FSS Act • Iodine content of salt at production level must be 30 ppm • And at consumption level it must be 15 ppm.

• Potassium iodate is used in India for iodisation of salt Impact indicators: indicators to assess iodine status and to monitor and evaluate the impact of salt iodization on the population • Median urinary iodine • Goitre assessment • TSH levels in neonates

• the principal impact indicator recommended is the population median urinary iodine level.

Sustainability indicators: indicators to assess whether iodine deficiency has been successfully eliminated

A combination of median urinary iodine levels in the population, availability of adequately iodized salt at the household level, and a set of programmatic indicators Fluorine

Sources: • Drinking water, tea, Fluoridated toothpastes and mouthwashes • Concentration of 0.5 to 0.8 mg/l in water is considered a safe limit

Deficiency: • Dental caries

Excess: • Dental fluorosis (>1.5 ppm) • Skeletal fluorosis (> 5 ppm)

Indicators for sustainable elimination of IDD

Salt iodisation- proportion of households using >90% adequately iodized salt Urinary Iodine excretion Median in general population 100-199 μg/l

Median in pregnant women 150-249 μg/l Not an essential mineral? (AIIMS 2010) a) Pb b) Mn c) Na d) Fe Iron is absorbed predominantly in (UPSC CMS 2012) a) Stomach b) Jejunum c) Ileum d) Colon The daily requirement of calcium during normal pregnancy is (UPSC CMS 2011) a) 250 mg b) 500 mg c) 1000 mg d) 2000 mg Which of these is not a constituent of metallo-enzymes? a) Copper b) Zinc c) Iron d) Nickel

For a patient to suffer from dental fluorosis, the fluorine intake through water has to be at least a) 1.5 ppm b) 1.0 ppm c) 0.5 ppm d) 5.0 ppm The RDA of Iron during pregnancy is- a) 21 mg b) 35 mg c) 25 mg d) 100 mg The target for the proportion of households using iodized salt is - a) 70% b) 80% c) 90% d) 100% BMI

Body Mass Index (Quetelet’s Index)

= Weight in Kg (Height in m)2 BMI Classification

BMI Classification <18.5 Underweight

18.5- 23 Normal

23-27.5 Pre-obese

>27.5 Obese Waist Circumference Males Females < 90 cm < 80 cm Waist-Hip ratio Males Females < 0.9 <0.8 Broca’s Index: Normal weight = (Height-100 cm) Ideal weight = 90% Normal weight

Ponderal’s Index = Weight in Kg (Height in m)3

Corpulence index = actual weight divided by desirable weight. WHO criteria for Severe Acute Malnutrition • Weight for height <-3SD • MUAC < 115 mm • Bilateral pedal edema

WHO criteria for Moderate Acute Malnutrition • Weight for height between -2SD to -3SD • MUAC between 125mm to 115 mm

Food Hygiene Pasteurization

Method Description Holder (Vat) method Milk is heated up to 63-63.5 o C for 30 min and then rapidly cooled to 5 o C High Temperature Milk is heated to 72 o C for 15 seconds and Short time (Flash then rapidly cooled to 4 o C method)

Ultra High Milk is heated to 125-150 o C for few Temperature seconds under pressure and then rapidly cooled to 4 o C Testing of Milk Laboratory test Remarks Specific gravity Should be 1.03 Measured using Lactometer or Pyknometer Gerber’s test Estimation of fat, must be atleast 3.5 gm/dl Measured using fat meter Solids not fat Must be atleast 8.5 gm/dl Iodine test Tests the addition of starch as adulterant Testing of Milk

Methylene blue test Tests keeping quality and bacterial contamination Phosphatase test Tests efficiency of pasteurization Bacteriological Standard plate count tests Coliform count Specific tests for Mycobacterium tuberculosis, Bacillus abortus Food Food Organism/ Food involved Clinical features toxication Neurolathyris Neurotoxin β-oxalyl-L- Kesari dal / Grass m α,β-diaminopropionic Pea (Lathyrus (Spastic acid (ODAP) sativus) paraplegia) β- N- oxalyly-amino-L- alanine (BOAA) Aflatoxicosis Caused by fungi Infestation of nuts Hepatocellular Aspergillus flavus, and cereals carcinoma, Aspergillus parasiticus hepatitis Aflatoxin Claviceps fusiformis Cereals Abdominal (St. Claviceps purpura cramps, Anthony’s Ergotamine vomiting, Fire) Ergocristine drowsiness Burning in extremities, peripheral gangrene Fusarium Fusarium incamatum Cereals Diarrhea, toxication Dexanevalinone vomiting Fumonisin Epidemic Sanguinarine Argemone Bilateral dropsy Dihydrosanguinarine Mexicana pedal edema, seeds/oil CCF contaminating mustard seeds/oil Endemic Pyrrolizidine Crotalaria Ascites, ascites alkaloids (jhunjhunia) jaundice mixing with Gondhli (Panicum miliare) Food Salmonella Agent - Salmonella typhimurium, Salmonella food cholera-suis, Salmonella enteridis. poisoning Source- farm animals, rodents transmit. Incubation – 12-24 hours Mechanism- acute enteritis and colitis Fever with chills

Staphyloco Agent- Coagulase positive staphylococcus aureus ccal food Mechanism- Enterotoxin-heat stable (intradietetic) poisoning Incubation- 1-6 hours Botulism

• Agent- Clostridium botulinum, a gram - negative, strict anaerobe, spore-forming bacillus • Source- Home-canned, home preserved foods • Pre-formed toxin acts on parasympathetic nervous system • Incubation- 12-36 hours • Mechanism- exotoxin- parasympathetic activation • Symptoms - vomiting, dysphagia, , ptosis, dysarthria, muscular weakness. • Frequently fatal - death occurring 4 to 8 days later due to respiratory or cardiac failure.

Clostridium Contaminated meat perfringens food Incubation- 6-24 hours poisoning

Bacillus cereus Spores germinate and multiply and release toxin Emetic form incubation- 1-6 hours Diarrheal form incubation- 12-24 hours Endemic ascites is caused by- (AIIMS 2006, 2008) a) Aflatoxin b) Sanguinarine c) Pyrrolizidine alkaloids d) Ergot alkaloids The following are characteristics of staphylococcal food poisoning, except- (AIIMS 2004) a)Optimum temperature for toxin formation is 37o C b)Intra-dietetic are responsible for intestinal symptoms c)Toxins can be destroyed by boiling for 30 minutes d)Incubation period is 1-6 hours The following tests are used to check the efficiency of pasteurization of milk except- (AIPME-2005) a)Phosphatase test b)Standard plate count c)Coliform count d)Methylene blue reduction test Characteristic of Bacillus cereus food poisoning is (AIIMS 2010) a)Presence of fever b)Presence of pain abdomen c)Absence of vomiting d)Absence of diarrhea Pasteurized milk is most commonly tested by: (AIPGME 2011) a)Phosphatase test b)Coliform test c)Catalase test d)Oxidase Test Which of the following will be abnormal in both acute and chronic malnutrition- (AIIMS 2007, 2012) a) Weight for age b) Height for age c) Weight for height d) BMI The health indicator obtained by dividing height by cube root of weight is: (UPSC CMS 2013) a) Quetelet’s index b) Brocca index c) Corpulence index d) Ponderal index Beta oxalyl amino alanine (BOAA) is found in: (UPSC CMS 2014) a) Argemone mexicana b) Lathyrus sativus c) Aspergilus flavus d) Crotolaria medicagenia Weight divided by height raised to 2 is used as an index known as (JIPMER 2003) a) Broca’s index b) Quetelet Index c) Ponderal’s Index d) Corpulence Index The test, which is not done to test for pasteurization is (JIPMER 2003) a) Methylene Blue test b) Coliform count c) Plate test d) Phosphatase test Which of the following indicators does not include the value of a person’s height in its formula? (UPSC CMS 2011) a) Quetelet’s Index b) Ponderal Index c) Lorentz’s Formula d) Corpulence Index The criteria for Severe Acute malnutrition includes – a) Weight for height <-3SD b) MUAC < 115 mm c) Bilateral pedal edema d) All of the above In Flash method of pasteurization, milk is heated to____ degrees Celsius a) 63 b) 72 c) 100 d) 125 Which of the following toxin is associated with Neurolathyrism? a) Dexanevalinone b) Phalloidine c) Diamino propionic acid d) Pyrrolizine alkaloids All are except a) Addition of colour to saccharin b) Addition of Vit A to food stuff c) Addition of extra nutrients to food stuff d) Iodization of salt Following are true of Botulism except a) Frequently fatal b) Bloody diarrhea c) Dysphagia d) Absence of fever The food poisoning with highest mortality of the following is- a) Salmonella food poisoning b) Botulism c) Staphylococcal food poisoning d) Clostridium perfringens food poisoning Hb Threshold (mg%) to label Anemia in Non-pregnant women (≥15.00 yr) is ______a) 13.0 b) 12.0 c) 10.5 d) 11.0 Stunting is ______weight for height but ______height for age- a) Normal; Low b) Low; Normal c) Low; Low d) High; low Acute malnutrition may be indicated by: a) Stunting b) Wasting c) Stunting and wasting d) All of the above With regards to food-borne pathogens, the danger zone of temperature is …………… 0 C for more than two hours. a) 30 to 45 b) 21 to 50 c) 5 to 60 d) 10 to 45

Cereals and pulses are considered complementary because: a) Cereals are deficient in methionine b) Cereals are deficient in methionine and pulse are deficient in lysine c) Cereals are deficient in lysine and pulses are deficient in methionine d) Cereal proteins contain non-essential amino-acids, while pulse proteins contain essential amino acids кінець

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