Nutritional dissorders

Guided by: Latha mam

04/11/23 1NUTRITIONAL DISORDERS

What is calorie?CALORIE - is the amount of energy needed to raise the temperature of one gram of water by one degree Celsius CALORIE = is represented by the letter C.


Essential nutrients

ProteinsFatsCarbohydratesVitaminsMinerals water


Main nutritional disordersObesityStarvationKwashiorkor MarasmusAnorexia nervosaBulimia nervosaVitamin deficiencyTrace element deficiency


ObesityObesity is defined as an excess of adipose tissue

that imparts health risk.

Etiology genetic predisposition diets largely derived from carbohydrates and fats

than protein rich food. hypothyroidism, cushings syndrome, insulinoma,

and hypothalamic disorders


Pathophysiology Obesity is associated with

increased adipose stores in the subcutaneous tissue, skeletal muscles, internal organs such as the kidneys, heart, liver and fatty liver is also more common in obese individuals. There is increase in both sizes number of adipocytes and there is hypertrophy as well as hyperplasia.


Obesity


Metabolic changesHyper insulinaemiaNon- Insulin dependant diabetesHypertensionHyper lipoproteinaemia: AtherosclerosisCoronary artery diseaseCholelithiasisCancerOsteoarthritis:

04/11/23 NUTRITIONAL DISORDERS 8

Serious health hazards of obesityStrokeCoronary artery diseasesHypertensionFatty liverDiabetesAtherosclerosisHyperlipidaemiaOsteoarthritis



Management of obesityNutritional therapyBehavior modification Support groups MEDICAL MANAGEMENT Drug therapy {appetite suppressing drugs} Phentermine, diethylpropion etc.SURGICAL MANAGEMENT Vertical banded gastroplasty Adjustable gastric banding


StarvationStarvation is a state of overall deprivation of

nutrients.

Etiology deliberate fasting famine conditions in a country or

community. secondary under nutrition such as chronic wasting diseases, cancers etc.


Signs and symptomsDry and scaly skin muscular weaknessAnemiaIncreased susceptibility to infectionsLoss of appetiteWound healing may be delayedBrittle nailsLoss of hairDepressionDecreased B P ,pulse, slight cyanosis.


Starvation


Nursing managementHealth promotionAcute interventionHealth educationTry to maintain an optimal body weight

TYPES OF SPECIALISED NUTRITIONAL THERAPY

Oral feeding Tube feeding nasogastric and nasointestinal

feeding gastrostomy and jejenostomy


Protein deficiency malnutrition

Kwashiorkor- Which is related to protein deficiency through calorie intake may be sufficient.

Marasmus- is starvation in infants occurring due to overall lack of calories.


KWASHIORKORClinical featuresOccurs in children

between 6 months 3 years of age

Growth failureWasting muscles but

preserved adipose tissue

Edema , localized or generalized, present

Enlarged fatty liverSerum proteins low Anemia presentAlternate bands of

light and dark hair

MARASMUSClinical features

Growth failureWasting of all tissues

including muscles and adipose tissue

Edema presentNo hepatic

enlargementSerum proteins lowAnemia presentMonkey-like face,

protuberant abdomen, thin limbs




MorphologyKWASHIORKORMorphologyEnlarged fatty liverAtrophy of different

tissues and organs but subcutaneous fat preserved

MARASMUSMorphologyNo fatty liverAtrophy of different

tissues and organs including subcutaneous fat




marasmusDiagnostic Evaluation

Severe hypo chromic anemia is generally diagnosed. The plasma proteins level is usually lowered unless hemo concentration is present.


Pathophysiology marasmus

When adequate calories are not ingested to fulfill the metabolic needs of the body, reserve food elements such as protein and fat in the tissues are used to sustain life. This process may be caused by

An inadequate diet or faulty eating habits Congenital anomalies that present the infant taking an

adequate dietDisease condition that interfere with the assimilation of

food Infections that produce anorexia and decrease the

infants ability to digest foodLoss of food intake through vomiting and diarrheaFood allergy that is not managed appropriate Emotional problems such as disturbed mother child

relations.04/11/23 24NUTRITIONAL DISORDERS

Nursing Management of marasmus

Management consists of providing a nutritional intake that is rich in the essential nutrients to correct the dietary insufficiency and to promote normal growth and development. Parenteral fluid therapy may initially be necessary to correct the electrolyte imbalance and dehydration and to restore kidney if oral feedings are not tolerated, hyper alimentation is used. Additional vitamins and minerals and blood transfusion may be necessary.


In addition to assisting with administering parenteral fluids and giving oral feedings, the nurse is also responsible for maintaining the infant’s body temperature within a normal range, providing for periods of rest and appropriate activity and stimulation, recording intake and output, daily weighing turning and preventing infection. The nurse carefully observes affected infants for infection of mouth, skin and respiratory and genitourinary tracts. These infections are appropriately treated when they occur. The infant is protected from other patient and care givers who have infections because infants who have marasmus may also have emotional deprivation, their care is like that for those who have failure to thrive.


Prevention of marasmus

The prevention of marasums consists of

Parent educationPrompt treatment congenital defectsPrevention of emotional disturbance


KWASHIORKOR


Pathophysiology KwashiorkorWhile growth is occurring, sufficient

nitrogenous food must be consumed to maintain a positive nitrogen balance. When inadequate amounts of the essential aminoacids are not provided, not absorbed or abnormally lost, protein under nutrition results. The impaired absorption or loss of protein may occur in infants and children who have chronic diarrhea, nephrosis, hemorrhage, burns or infection. Nutritional edema, results when the body, lacking sufficient intake or sustaining a loss of high quality protein, burns its own tissues and destroys the plasma protein so that the level of plasma albumin becomes low.


kwashiorkor


PROTEIN CONTENT FOODSEggsCow’s milkCheeseMeat cookedFish cookedRice cookedSoy beans White potatowheat germNuts



Nursing Management The management of infants and children

who have kwashiorkor includes replacement of the missing nutrients and treatment for any acute problems such as diarrhea, renal failure and shock. The dietary intake of protein and calorie in increased gradually, skin milk, synthetic amino acid mixtures or case in hydrolysates may be given to supplement the usual diet. Vitamins and minerals, especially vitamin 4, magnesium and potassium are added to the intake to correct any deficiencies.


The accompanying anemia can be corrected by administering iron and folic acid. In spite of this management the infant or child may initially loss weight because of the loss of edema fluid. However improvement can gradually be seen. Infections or infestations are treated appropriately. The long term management consists of feeding the child a diet with adequate calories, especially one high in protein of good biologic quality.


Prevention Prevention consists of providing a diet

containing an adequate quality of protein of high biologic quality for all infants and children. In those areas where kwashiorkor is endemic parents should be taught the nutritional needs of all family members and adequate amounts of food should be provided to fulfill these needs.


Anorexia nervosaAn eating disorder in which the person

experiences hunger but refuses to eat because of a distorted body image, leading to a self perception of fatness. Anorexia nervosa is a condition of self-generated weight loss usually seen in adolescent girls and young women, but also in middle-aged women or men


Etiology of eating disordersAlthough the cause of eating disorders is

not certain, several factors are likely to contribute to development of the disorders. Socio cultural and environmental factors including media and peer influences, family factors including parental discord, and biologic factors including genetics, neurotransmitter regulation, and hormonal functioning have been implicated. Negative affect, low self-esteem, and dieting behavior commonly predate the onset of an eating disorder.


Clinical manifestations of anorexia nervosaClients with anorexia nervosa are usually first

introduced to the health care system when the disordered eating behavior results in obvious weight loss. Clients may limit themselves to 200 to 500 kcal/day-only 60% to 70% of the amount needed for ideal body weight. Physical manifestations include dry skin, pallor, bradycardia, hypotension, intolerance to cold, constipation, and amenorrhea


Pathophysiology The pathophysiologic changes associated with

anorexia nervosa are similar to those seen in starvation. When caloric intake is severely limited, the body adapts by using the body's fat stores and sparing nitrogen stores. With prolonged starvation, significant shifts in fluid and electrolyte balance can occur and can be life-threatening.

The hypothalamus responds to the lack of nutrient intake with changes in pituitary function, resulting in amenorrhea and infertility. The extent of malnutrition will determine the pathophysiologic changes observed.



Bulimia nervosa An eating disorder characterized by

uncontrollable binge eating alternating with vomiting or dieting.

Bulimia nervosa is a less serious and entirely separate illness. Clients with bulimia nervosa tend to maintain a relatively normal weight, but go through periods of eating excessively (binging) and vomiting (purging) gastric contents to prevent weight gain. It has been suggested that bulimia nervosa is a form of depressive illness.


Clinical manifestations of bulimia nervosa Clinical manifestations of bulimia nervosa include

episodes of binge eating followed by self-induced vomiting. The eating and vomiting episodes occur most often in the late afternoon and evening and are done in secret. Some clients may abuse laxatives and diuretics as well. Personality characteristics typical of clients with bulimia are related to depression. Physical manifestations may not be as obvious, because the client with bulimia may be of normal weight without any depletion of fat stores. Less obvious clinical manifestations are erosion of tooth enamel from frequent vomiting and esophageal and throat irritation.



Nursing management of eating disorders Outcomes The client will be able to resume normal earning behaviors. In

clients with severe nutritional depletion, the client will be able to regain weight at a safe rare (1 to 2 pounds/week).

Interventions: When caring for a client with anorexia nervosa, help the client select foods from the Food Guide Pyramid for a nutritionally balanced diet. The client is usually allowed to refuse a specific number of foods (such as two or three) so that some sense of control is felt. Observe the client during mealtimes. Be supportive during mealtimes and, if needed, stay with the client after he or she eats to prevent him or her from purging. Education related to nutrition must include the client's family, care givers, or co-residents. An accurate calorie count and regular monitoring of weight are other important interven tions. Parenteral or enteral nutrition may be needed forr refractory clients with extreme malnutrition.


Management cond………Outcomes The client will lose 1 to 2 pounds per week

until ideal body weight is achieved and maintain ideal body weight thereafter

Interventions Teach the client how to use the Food Guide

Pyramid to select a healthy diet with portions of appropri ate size. Encourage the client to eat slowly and develop a regular exercise pattern. Encourage the client to approach food, eating, and self-image in a new way. Provide emotional support and supervision for the client to overcome stressful periods and break the binge-and-purge cycle.


Management cond………Outcomes The client will develop a more normal image of self, as

evidenced by statements concerning increased self-esteem by the client's ability to overcome the eating disorder.

Interventions

Recognize that clients suffering from eating disorders typically have low self-esteem. These clients see the regulation of food and exercise of self-control in eating patterns and amounts as ways to prove themselves successful. It is important that the client's significant others help the client find other areas of self-regard. It is expected that the client will overcome the eating disorder with consistent and continued treatment and that weight will return to normal.


VitaminsFat soluble vitaminsa) vit A b) vit Dc) vit E d) vit K water soluble vitaminsa) vit Cb) vit B complex


Vitamin A [retinol]Physiologic functions of retinolMaintenance of normal vision in reduced light.

This involves synthesis of rhodopsin, a light sensitive pigment in the rods and cones of retina, by oxidation of retinol. This pigment then transforms the radiant energy in to nerve impulses.

Maintenance of structure and function of specialized epithelium

Maintenance of normal cartilaginous and bone growth.



Deficiencies of vit A

Night blindnessOcular lesionsCutaneous lesionsBitot spotXerophthalmia


Bitot’s spot


Pathological changes: - Consequent to vitamin A deficiency following pathologic changes are seen.

Ocular lesions: - Lesions in the eyes are most obvious. Night blindness is usually the first sign of vitamin A deficiency. As a result of replacement metaplasia of mucus secreting cells by squamous cells, there is dry and scaly sclera conjunctiva (xerophthalmia). The lacrimal duct also shows hyperkeratosis corneal ulcer may occur. Bitot's spots may appear which are focal triangular areas of opacities due to accumulation of keratinized epithelium.


contdIf these occur on cornea, they impede

transmission of light. Ultimately, infection, scarring and opacities lead to blindness.

Cutaneous lesion:- The skin develops popular lesions giving toad like appearance (xeroderma). This is due to follicular hyper kurtosis and keratin plugging in the sebaceous gland.


SourcesThe major sources of retinol are liver, dairy products, eggs and carotenes are found in varying amounts in vegetables and fruits, especially in most of the dark green leafy and bright orange ones. Carotenes may also be present in the foods listed above that naturally contain retinol.

Recommended intake The 1980 RDA for Vitamin A is (5000 IU)

for men and (4000 IU) for woman.


Management

Mild to moderate cases of deficiency can be treated by daily oral dose of 10,000 IU of fat soluble vitamin A for 10 days. In severe cases larger dose (50,000 IU) is recommended for one week. A single massive dose of 50,000 IU of vitamin A every six months is prophylactic for children below six years of age.


Vitamin D[Calciferol]Functions Vitamin D is of almost importance in the

regulation of calcium and phosphorous metabolism in the body. It serves to maintain proper blood levels of calcium and phosphorous by promoting their intestinal absorption and by mobilizing these minerals from the skeleton when needed. Mineralization of the skeleton and teeth requires an adequate supply of vitamin D.



Sources

Exposure to straight, fortified foods, fish lives oil are good sources of vitamin D natural foods are poor sources at vitamin D although small amounts are present in egg yolk, liver, and fish such as herring, sardines, tuna and salmon.

Recommended dietary allowances

Vitamin D is now considered more as a pro hormone than a vitamin. Exposure to sunlight even for 5 minutes per day. A specific recommendation of a daily supplement of 400 IU is made.


Vitamin D deficienciesTetaniRicketsOsteomalacia


TetaniThis is characterized by low serum

calcium (less than 7.5 mg per 100ml) muscle twitching, cramps, and convulsions. It results from insufficient absorption of calcium or vitamin D, or from a disturbance of the parathyroid gland.


Osteomalacia Osteomalacia frequently called as adult rickets, occurs when there is lack of vitamin D and calcium. It may also occur when there is an interference with fat absorption and hence also vitamin D absorption.


Osteomalacia


Osteomalacia


RicketsEtiology Poor exposure to sunlight may also be

related to the inactivity of the malnourished children. Disturbed metabolism and poor synthesis of vit D from the skin ,malabsorption state , diarrheal diseases and excessive phylate with low calcium and low phosphate content of the food may well be some causes of rickets in malnourished children.


Rickets


Rickets clinical featuresHead-Increased size and delayed

closure of fontanels , craniotabes Teeth-delayed dentitionThorax- rachitic rosary, pigeon chestSpine-scoliosis , kyphosisLimbs-widening of wrists, ankles and

other epiphysis , genu valgum


rickets


Management In case of rickets recommended dose of vit D is 10000 to 50000units per day


Rickets heals promptly with 4,000 IU of oral vitamin D per day administered for approximately one month.. The bone abnormalities (visible by x ray) generally disappear gradually over a period of 3-9 months. Parents are instructed to take their infants outdoors for approximately 20 minutes per day with their faces exposed. Children should also be encouraged to play outside. Foods that are good sources of vitamin D include cod liver oil, egg yolks, butter, and oily fish. Some foods, including milk and breakfast cereals, are also fortified with synthetic vitamin D.


Rickets


Vitamin E[Tocopherol]Functions Vitamin E is needed for normal stability

of red blood cells. In animals it has been shown to be essential for normal reproduction and for integrity and muscle and for nerves. There is no sound scientific basis for claims in the lay literature that vitamin E promotes fertility and sexual performance..



Source The richest source of vitamin E are

the vegetable oils that are risk in poly unsaturated wheat germ, nuts, whole grains, legumes and certain vegetables.

Another sources Soybean oil, sunflower oil, mayonnaise walnut, lima beans, sweat potatoes, spinach, fish, liver, shell fish, eggs.


Recommended intake Although the 1980 RDA has been set at

10 mg tocopherol for men and 8 mg for woman this should be considered to be a recommendation for people consuming customary American diets.


Vitamin E deficiency Vitamin E deficiency is extremely rare

in humans. It is limited to those individuals with fat malabsorption, or patients on total parenteral nutrition, or in formula fed premature infants. Changes occurring in severe deficiency include, increased hemolysis of red blood cells, creatinuria deposition of brandish ceroid pigments in smooth muscles and , in some cases, development of a form of muscular dystrophy


Management of Vitamin E disorders Vitamin E has been used in daily doses of 400

to 800 mg for the treatment of diverse conditions such as habitual abortion, sterility muscular dystrophy diabetes ischemic heart disease, skin disorders and anemia in infants. Benefit has been reported in some of these cases but none has been established in clinical trails.

Administration of 3 to 4 g of tocopherol daily over long periods has not produced any toxic effects in human beings. However several reports of adverse effects such as elevation of serum lipids, impaired blood coagulation and reduction of serum thyroid hormones suggest that indiscriminate ingestion of excessive amounts over long periods should be avoided.


Vitamin K Vitamin K is concerned with synthesis of coagulation factors 2,7,9,and 10 in the liver. Green leafy vegetables, soybeans and fish are it’s natural sources. Enough of these vitamin is produced by intestinal flora



Function Vitamin K is essential for the hepatic

synthesis of prothrombin and certain others factors involved in blood clotting. For this reason it is sometimes called the antihemorrhagic it also appears to have a role in some metabolism.

Sources Green leafy vegetables, cauliflower, broccoli

and liver all the richest dietary sources of vitamin K. However, bacterial synthesis of vitamin K in the gut accounts for a large proportion of a persons daily supply initially a new born infant has a sterile gastro intestinal tract and thus cannot synthesize significant amounts of vitamin K for a few days since milk is low in vitamin K the vitamin is routinely administered to new borne.


DEFICIENCY DISORDERS

Hemorrhagic disease of new born:- The new born infants are deficient in vitamin K because of minimal stores of vitamin K of birth, lack of established intestinal flora for endogenous synthesis and limited dietary intake since breast milk is a poor source of vitamin K.

Biliary obstruction:- Bile is prevented from entering the bowel due to biliary obstruction so that this fat soluble vitamin cannot be absorbed.


Malabsorption syndrome:- Patients suffering from malabsorption of fat develops vitamin K deficiency e.g. coelic disease, sprue, pancreatic disease, hyper motility of bowel etc.

Diffuse liver disease:- Patients with diffuse liver disease (e.g. cirrhosis, omyloidosis of liver hepatocellular carcinoma, hepatoblastoma) have hypoprothrombinaemia due to impaired synthesis of prothrombin administration of vitamin K to such patients is of no avail since liver, where prothrombin synthesis utilizing vitamin K takes place, is diseased.


Deficiency of vitamin KDeficiency of vitamin K causes defective blood coagulation

Recommended dietary allowancesBecause of variation is the intestinal synthesis of vitamin K no special recommendation for allowance has been made. The food and nutrition board has established 1-2mg of vitamin K per kg body weight to be safe and adequate intake.


ThiamineThiamine (vitamin B1), a water-

soluble vitamin, is an essential coenzyme for metabolism of carbohydrates



sources It is freely distributed in animal and

vegetable products such as liver, egg, yolk, pork, legumes, yeast, pericarp and germ of cereals, autolysis yeast (marmite), and milk. Polishing the rice considerably destroys its thiamine content


Clinical FeaturesThiamine deficiency leads to the disease,

beriberi. It occurs usually in infants (wet beriberi) though older infants and children may also suffer from its chronic form (dry beriberi).

The earliest symptoms, occurring in early infancy (especially if the mother is providing thiamine-deficient breast milk), include restlessness, bouts of excessive crying (as if the infant is having an abdominal colic), vomiting, abdominal distention, flatulence, constipation/ and insomnia.



Treatment/management As soon as the diagnosis is convincingly made,

the child must receive 10 mg of thiamine intravenously. In the subsequent three days, he should be given 10 mg of the vitamin intramuscularly twice daily. Over the next six weeks, 10 mg daily should be administered orally.

The breastfeeding mother should receive thiamine therapy simultaneously.

Prognosis is excellent provided reasonable intake of thiamine is ensured.

PreventionEnsuring that at least 0.4 mg of thiamine is provided

in the daily diet (thrice the quantity in case of pregnant and lactating women) prevents beriberi.


Riboflavin Riboflavin (vitamin B2), another water-soluble

vitamin, is a constituent of flavoprotein enzymes vitally concerned with the intermediary metabolism of carbohydrates. It is found in both animal and vegetable foods such as liver, fish, egg, kidney, meat, beans, yeast, green leafy vege tables, cereals, legumes, groundnut and milk (5 times more in cow milk than in human milk).



Riboflavin deficiencyClinical Features

Manifestations include angular stomatitis, cheilosis (fissuring of lips), nasolabial seborrhea and, occasionally magenta (purplish-red, smooth) tongue. There may occur corneal injection (vascularization) at the limbus, leading; to excessive lacrimation, photophobia, eye pain and later interstitial keratitis.


Treatment/managementTherapy consists in administering riboflavin, 3 to

10 mg orally or 2 mg intramuscularly daily for a few days. This / should be followed by 10 mg orally daily for about three weeks.

With this regimen, response is good. Complete recovery occurs provided that adequate intake of vitamin B2 is ensured in the weeks and months ahead.

PreventionIn order to prevent riboflavin deficiency, it should

be ensured that the daily diet provides at least 0.6 mg riboflavin per 1,000 kcal. It is advisable to administer supplements of riboflavin (the whole B-complex may . be still better) to the infants and children belonging to vulnerable categories.04/11/23 92NUTRITIONAL DISORDERS

Nicotinic acidNicotinic acid (niacin) is also involved in

the carbohydrate metabolism and plays vital role in the functioning of the skin, gastrointestinal tract, central nervous system and hemopoietic system.

This vitamin may be obtained either from the natural food sources or from the tryptophan endogenously. The natural food sources include milk, liver, pork, cheese, yeast, cereals, etc.



Clinical FeaturesThe disease caused by nicotinic acid deficiency is

called pellagra. It usually occurs in children of school-going age.

The characteristic lesions are seen over the exposed areas of the skin, such as limbs, neck, ("Casal necklace") and cheeks. It is worth noting that the lesions are symmetrical, of desquamating pigmentary dermatitis type and are aggravated by sunlight.

There is a widespread gastrointestinal inflammation, leading to red and sore tongue, dysphagia, nausea, vomiting and diarrhea.


Clinical Features

Just like diarrhea, dementia is encountered much less childhood than in adults. Most children with pellagra are, no doubt, quite apathetic.

Anemia as also other signs of malnutrition are usually present.


Pellagra


Pellagra


Pellagra


Treatment/management Nicotinamide, 50 to 300 mg

daily in divided doses orally, given for two weeks followed by adequate supply of B-complex vitamins in diet brings about complete recovery.

Prevention The disease may be prevented

by providing a balanced diet containing 5 to 10 mg daily supply of nicotinamide.


Pyridoxin Pyridoxine (vitamin B6) plays a vital role in

the metabolism of proteins and fatty acids. It is claimed to have a role in blood formation, in proper functioning of the nervous system and in conversion of tryptophan into nicotinic acid.

Its natural sources include liver, egg yolk, meat, wheat] germ, soybeans, yeast, peas, pulses and cereals. It ii found in only small quantity in most vegetables am milk.



Clinical Features of deficiency of pyridoxin

The manifestations include convulsions and microcytic, hypo chromic anemia refractory to iron therapy. Growth retardation and gastrointestinal symptoms like diarrhea may occur. Seborrheic dermatitis around nose and eyes, and sensory neuropathy occur only uncommonly in children. Cheilosis and glossitis are infrequent in childhood.


Growth retardation


Treatment/management

Administration of 5 mg of pyridoxine intramuscularly followed by 0.5 mg daily orally for two weeks causes complete recovery.


Vitamin C[ascorbic acid] Ascorbic acid, which structurally resembles

a monosaccharide sugar, is known to play important role in oxidation of tyrosine and phenylalanine, in formation of hydroxyproline, in preventing de polymerization of collagen and in hemopoiesis.

Deficiency of vitamin C, though quite common in its subclinical form, has virtually disappeared in its overt form from the affluent countries. But, its frank cases still continue to be seen from time to time in some parts of the developing regions.



sourcesFruits and vegetables are the only

significant sources of vitamin C.Recommended intake For adults 60 mg daily. This level

of intake is expected to maintain a body pool of 1500mg ascorbic acid.


Scurvy occurs usually in infants between the age of 6 months to 2 years. No age is a bar, however.

Infantile scurvy is characterized by gross irritability, excessive crying and tenderness to touch, more so in the lower limbs. The infant adopts the so-called "frog-position”. The posture of the lower limbs gives an impression as though these are paralyzed

The palpable sub periosteal hemorrhage into the lower third of the femur may contribute to pain, thus preventing movements of the leg further and strengthening the impression that the limb may be paralyzed.


Hemorrhages may occur into the skin and mucous membranes. Hemorrhages into the gums may result in spongy, swollen, bluish purple gums, especially about the erupted teeth. Hemorrhages in the internal organs may cause hematuria, melena, proptosis and subdural swellings. Mild to moderate anemia is usual.

Scorbutic rosarymay result from posterior displacement of the sternum. Unlike rachitic rosary, it is tender,-sharp and angular and has a "step-shaped" configuration the sternum, being depressed.


scurvy


Treatment/management It consists in giving a dose of 500 mg of

vitamin C followed by a daily dose of 100 to 300 mg for several weeks. Oral administration is good enough.


Folic Acidfunctions Folic Acid is needed for energy production, protein metabolism, the formation of red blood cells and it is vital for normal growth and development

SourcesFound in beans, beef, bran, barley, brown rice, cheese, chicken, dates, green leafy vegetables, lamb, lentils, liver, milk, oranges, organ meats (like liver), split peas, pork, root vegetables (like carrots), salmon, tuna, whole grains, whole wheat and yeast.



DEFICIENCY SYMPTOMS:

A deficiency of Folic Acid may contribute to anemia, depression and anxiety,, and birth defects in pregnant women, sore tongue, and fatigue.


Vitamin B12:Vitamin B12 is a very large molecule and requires a special mechanism of absorption. Vitamin B12 functions in all the cells but especially those of the gastrointestinal tract and bone marrow and the nervous system.

Sources : Found in beef, blue cheese, cheese, clams, crab, fish, eggs, herring, kidney, liver, mackerel, milk and milk products, pork, seafood and tofu. It is not found in vegetables - only in animal sources.

BODY PARTS AFFECTED:liver, nerves, red blood cells, gastrointestinal tract.



DEFICIENCY SYMPTOMS:

Appetite loss, diminished reflex responses, fatigue, irritability, memory impairment, mental depression and confusion, nervousness, pernicious anemia, unpleasant body odor, walking and speaking difficulties, weakness in arms and legs. A deficiency can cause problems with digestion, absorption of food, metabolism of carbohydrates and fats, nerves, fertility, growth and development. There can also be hallucinations, memory loss, eye disorders, and anemia.


Recommended dietary allowances About 1 mg of vitaminB12 is required to

replace the daily obligatory losses.

Treatment/management Vitamin B12 administered in doses 250-

1000mg intramuscularly.


TRACE ELEMENTS DEFICIENCIES

Several minerals in trace amounts are essential for health since they form components of enzymes and cofactors for metabolic function besides calcium and phosphorus required for vitamin D manufacture, others include iron, copper, iodine, zinc, selenium, manganese nickel chromium, molybdenum, fluorine


Iron Iron is best known for being an active part of

hemoglobin in red blood cells but it is also a constituent of the muscle protein myoglobin and of a variety of protein that speed up chemical reactions within the body.

Sources Rating foods as sources of iron requires

consideration of the bioavailability of the iron they contain in general flesh foods are the best sources because they contain heam iron. Some plant foods appear to be much better source of iron than they actually are.


ZincRecognition of the importance of zinc as a

nutrient is steadily increasing. growth ,sexual development , wound healing , ability to fight infections sense of taste, night vision, healthy epithelial tissue, and other vital functions depend upon an adequate supply of zinc.

Sources Flesh foods are the most reliable sources of zinc

because they contain reasonably high amount of zinc. Red meats especially beef are higher in zinc. among plant foods sun flower seeds are good sources of zinc. Whole grains ,legumes and vegetables are richer in zinc.


IodideA regular supply of iodide is needed for the

production of the thyroid hormones, thyroxine and triidothyronine. Lack of iodine results in endemic goiter

SourcesIodized salt


Copper Copper participates in many metabolic

reactions that are necessary for normal development and maintenance of the skeleton, red blood cell production, normal skin and hair, and other functions.

Sources Oysters are recognized as the leading source


Chromium

Chromium is essential for normal utilization of glucose. Chromium is active in the body only in the form of a complex molecule called glucose tolerance actor. Meat, cheese, and whole grains are also reported to be good sources.


Deficiency disorders of trace elements

Iron:- Microcytic ,hypochronic anemia Copper:- Muscle weakness, neurologic

defectIodine:- Goiter and hyperthyroidismZinc:- Growth retardation, infertilitySelenium:- Myopathy, cardiomyopathy


GOITER


Goiter


Growth retardation


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