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133Nutrition and Health
Table 3.5: Recommended minerals intake for individuals
Age group Ca Mg P F Fe I
(years) (mg/ (mg/ (mg/ (mg/ (mg/ (µg/
day) day) day) day) day) day)
Children
1–3 600 50 460 0.7 9 90
4–8 600 70 500 1 13 90
Male
19–70 600 340 700 4 17 150
Female
19–70 600 310 700 3 21 150
Importance of Water
There is no life without water. Water is the essential constituent
of living cell protoplasm. It is a necessary vehicle for all the
metabolic processes. Water constitutes nearly two-thirds of the
total body weight. The use of safe and potable drinking water
is of greatest importance in maintaining positive health
measures. On average every individual requires 150 to 200 liters
of water every day.
The main important functions of water in the human body
are:
1. It helps in digestion.
2. It helps in the absorption of nutrients from the stomach
and intestine.
3. It is essential for organs (like the brain, heart, lungs,
kidney, liver, etc.) functioning.
4. It plays an important role in the regulation of body tempe-
rature.
5. It is very important for the activity of muscles and joints.
6. It lubricates the joints and thus overcomes the friction and
damage between them.
7. It lessens the burden on the kidneys and liver by flushing
out waste products.
Importance of Fibers
Fibers, also known as roughage, are substances that are not
digested or absorbed by the body. Fibers are mainly found in
134 Social Pharmacy
fruits, vegetables, legumes, nuts, and whole grains. Foods
containing fibers relieve constipation; maintain a healthy
weight, and lower the risk of diabetes, heart disease, and some
types of cancer.
Fibers are divided into two categories:
a. Soluble fibers: This type of fiber dissolves in water and
helps to lower glucose levels and cholesterol levels.
Examples of foods containing soluble fibers include
oats, chia seeds, nuts, beans, peas, lentils, citrus fruits,
barley, apples, and blueberries.
b. Insoluble fibers: This type of fiber does not dissolve in
water and passes unchanged through the digestive
system. It increases the bulk of the stool and helps to
relieve constipation and aids in the digestion process.
Grains, wheat bran, brown rice, legumes, leafy green
vegetables, almonds, walnuts, nuts, and fruits (e.g.,
pears and apples) are good sources of insoluble fibers.
Benefits of a High-fiber Diet
1. Normalizes bowel movements: Dietary fibers increase the
softness and bulk of stool. A soft and bulky stool relieves
constipation. Fibers also help to solidify the watery stool.
2. Maintain bowel health: A high-fiber diet lowers the risk of
diverticular disease and colorectal cancer. Diverticulosis is
a condition in which small, bulging pouches develop in the
digestive tract.
3. Lowers cholesterol levels: Soluble fibers lower total blood
cholesterol levels, blood pressure, and inflammation.
4. Controls blood sugar levels: Fibers improve blood sugar
levels and reduce the risk of developing type 2 diabetes.
5. Weight management: High-fiber foods tend to be more
filling than low-fiber foods hence one is likely to eat less
and stay satisfied longer. Also, high-fiber foods tend to
take longer to eat and to be less “energy dense,” which
means they have fewer calories for the same volume of
food.
135Nutrition and Health
Balanced Diet
A diet is the kind of food on which a person or group lives. A
balanced diet is a diet that contains a variety of foods in such
quantities and proportions that the body’s need for amino acids,
vitamins, minerals, fats, carbohydrates, and other nutrients is
adequately met for maintaining health, vitality, and general
well-being. Thus a balanced diet contains an adequate amount
of all the nutrients required by the body to grow, remain
healthy, and be disease-free. It also makes a small provision
for extra nutrients to withstand a short duration of leanness. A
balanced diet protects the people from nutritional deficiencies.
Any balanced diet should meet:
i. The daily requirement of proteins (equivalent to 15–20% of
daily energy intake).
ii. Fat requirement (equivalent to 20–30% of daily energy
intake).
iii. Carbohydrates, rich in natural fiber to constitute
remaining food energy.
iv. The requirement of micronutrients.
A balanced diet formulated by the Indian Council of Medical
Research (ICMR) is given in Table 3.6. In the wake of the
Table 3.6: Balanced diet formulated by ICMR
Food item Adult man Adult woman Pregnant
(moderate work) (moderate work) woman
[g/day] [g/day] [g/day]
Cereals/millets 360 300 325
Pulses* 120 90 90
Green leafy vegetables 100 100 100
Other vegetables 200 200 200
Roots and tubers 100 100 100
Fruits 150 150 150
Milk 300 300 400
Oil and fats 30 20 25
Oil seeds and nuts 30 30 40
* In the case of non-vegetarians 50% of pulses can be substituted by (i) one egg or 30 g of
meat or fish, (ii) an additional 5 g of fat or oil; 100% of pulses can be substituted by (i)
two eggs or 50 g of meat or fish, (ii) additional 10 g of fat or oil.
136 Social Pharmacy
COVID-19 pandemic, the general public is now more aware of
the importance of healthy food to increase immunity and keep
communicable diseases at bay.
A balanced diet is considered the key to preventing most of
the nutritional deficiency diseases and viral/other infections
(communicable diseases). In this context, a community
pharmacist can play a key role in educating the general public
about different aspects of nutrition and health.
Malnutrition
Adequate nutrition enables individuals to grow, mature,
reproduce, and function in a healthy and normal manner.
Undernutrition means a shortage in the total essential nutrients
in the diet caused by an insufficient supply of food.
Malnutrition means bad nutrition whether due to deficiency
or excess of one or more nutrients.
Malnutrition is a condition that results from nutrient
deficiency or overconsumption. Malnutrition may affect any
person, but the following persons are at a higher risk:
1. Children, pregnant and breastfeeding women.
2. Poor people having low socioeconomic status.
3. Children and old aged people.
4. People suffering from Crohn’s disease or ulcerative colitis
affect nutrient absorption.
Types of malnutrition
a. Undernutrition: This type of malnutrition is caused due to
inadequate protein, calories, or micronutrients including
vitamins and minerals, especially iron, zinc, vitamin A,
and iodine. It leads to low weight-for-height (wasting), low
height for age (stunting), low weight for age (underweight),
and micronutrient deficiencies or insufficiencies (a lack of
important vitamins and minerals). Undernutrition can
increase the risk of death.
b. Overnutrition: Overconsumption of certain nutrients,
such as protein, calories, or fat, can also lead to over-
nutrition. This usually results in overweight or obesity and
137Nutrition and Health
diet-related non-communicable diseases (such as heart
disease, stroke, type 2 diabetes, and cancer). Overnutrition
results from the overconsumption of high-calorie foods
such as fried and sugary foods that are high in calories and
fat. Even micronutrient deficiencies can also occur with
overnutrition in cases where the persons take excessive
calories but do not get enough vitamins and minerals at the
same time.
Both types of malnutrition (undernutrition and overnutri-
tion) can lead to health problems and nutrient deficiencies.
Signs and symptoms of malnutrition: The signs and
symptoms of malnutrition depend on the type of nutrition.
Undernutrition results from insufficient intake of nutrients in
the diet. The main symptoms of undernutrition are as follows:
1. Weight loss.
2. Loss of fat and muscle mass.
3. Hollow cheeks and sunken eyes.
4. Swollen stomach.
5. Dry hair and skin.
6. Delayed wound healing.
7. Fatigue.
8. Difficulty in concentrating.
9. Irritability.
10. Depression and anxiety.
Assessment of malnutrition
Various parameters to assess malnutrition are:
1. Weight changes.
2. Body mass index (BMI) (<18.5 BMI indicates malnourish-
ment).
3. Blood tests.
4. Physical examination of the body.
Common causes of malnutrition: The main causes of
malnutrition are:
1. Insufficient food intake.
2. Digestive problems.
138 Social Pharmacy
3. Malabsorption of nutrients due to health problems such as
Crohn’s disease, celiac disease, and bacterial overgrowth
in the intestine.
4. Excessive alcohol consumption.
5. Mental health disorders.
6. Limited mobility.
Prevention of malnutrition
1. Take iron, zinc, and iodine pills as supplements.
2. Eat a balanced diet.
3. Exercise daily.
4. Regular monitoring of treatment by keeping a watch on
overweight and height measurements of children.
Treatments for malnutrition
Treatment for malnutrition depends on the underlying cause
of malnutrition.
1. Dietary changes and supplements:
i. Eat a balanced diet, high in energy and nutrients.
ii. Eat ‘fortified foods’ that contain extra nutrients.
iii. Take healthy snacks between meals.
iv. Take drinks full of calories.
v. Treatment for any underlying medical conditions
causing malnutrition.
vi. Take extra nutrients in the form of vitamin and mineral
supplements.
2. Feeding tubes: This is an alternative way of giving
nutrients in case a person has dysphagia. In the case of
dysphagia, feeding is done through a nasogastric tube (a
tube passed through the nose into the stomach)
percutaneous endoscopic gastrostomy (PEG) tube (a tube
placed directly into the stomach or gut through the skin on
the tummy), or parenteral nutrition (parenteral nutrition).
3. Care and support services: Some malnourished people
need extra care and support that may be given by:
i. Home care visitors to shop for food or cook.
ii. Occupational therapist who can identify and treat
problems with daily activities.
139Nutrition and Health
iii. ‘Meals on Wheels’ by the local authority.
iv. Speech and language therapy by a speech therapist to
help with swallowing problems.
4. Treating malnutrition in children:
i. Increased intake of foods high in energy and nutrients.
ii. Support for families to help them manage factors
affecting the child’s nutritional intake.
iii. Treatment for any underlying medical conditions
causing malnutrition.
iv. Vitamin and mineral supplements.
v. High-energy and protein nutritional supplements.
vi. Regular monitoring of treatment by keeping a watch
on overweight and height measurements of children.
Nutrition Deficiency Diseases
Nutrient deficiency diseases can be the result of poor nutritional
intake, chronic health conditions, acute health conditions,
medications, altered nutrient metabolism, or a combination of
these factors. Such diseases can impact the levels of both
macronutrients and micronutrients in the body. They can lead
to alterations in energy metabolism, immune function,
cognitive function, bone formation, and/or muscle function,
as well as growth and development if the deficiency is present
during fetal development and early childhood.
a. Protein Energy Malnutrition (PEM)
Diseases arising due to the lack of calories and deficiency of
protein in children below 5 years of age are kwashiorkor,
marasmus, and marasmic kwashiorkor.
1. Kwashiorkor: Kwashiorkor means ‘red boy’. It is a severe
protein deficiency disease usually seen in children
between the age groups of 1 to 5 years. It is most common
in poor rural children.
The principal clinical features include:
i. Retarded growth
ii. Anemia
iii. Loss of appetite
140 Social Pharmacy
iv. Edema
v. Diarrhea
vi. Scanty hair growth
vii. Tissue swelling
viii. Loss of pigmentation
ix. Apathy.
Pure cases of kwashiorkor can develop within a few weeks
and the patients sometimes have normal weight for age. It
is less common than marasmus. Treatment consists of a
diet comprising largely of dry skim milk. Improving the
quantity and quality of proteins in the diet can prevent the
disease.
2. Marasmus: It generally occurs in children between age
groups of 0.5 to 5 years. This condition occurs at a younger
Fig. 3.2: Kwashiorkor
Fig. 3.3: Marasmus
141Nutrition and Health
age than kwashiorkor. The characteristic syndromes
include failure to gain weight, wasting of muscles, and
subcutaneous fat. The child is irritable but feels a good
appetite.
The difference between kwashiorkor and marasmus is
explained in Table 3.7.
Table 3.7: Difference between kwashiorkor and marasmus
S. Kwashiorkor Marasmus
No.
1. Develops in children of age Develops in infants due to a defi-
between 1–5 years due to ciency of proteins, fats, and
deficiency of proteins and carbohydrates
2. Edema is present Edema is absent
3. Scanty hair growth Normal hair growth
4. Loss of pigmentation No patches of pigmentation and
desquamation on the skin
5. Moon face Old man’s face
6. Subcutaneous fat is present Subcutaneous fat disappears
7. Enlarged fatty liver No fatty liver
8. Mild or no muscle wasting Severe muscle wasting
9. Poor appetite Voracious feeder
10. Skin appears to be swollen Skin is dry and wrinkled
11. Abdominal distension No abdominal distension
3. Marasmic-kwashiorkor: Marasmic-kwashiorkor has
combined features of both marasmus and kwashiorkor
conditions. Severe protein-energy malnutrition has a
combined spectrum from marasmus to kwashiorkor.
Children have some skin lesions, hair changes, and fatty
liver (as in kwashiorkor) together with the wasting of
marasmus. Malnourished children are mostly depleted in
other nutrients also.
b. Treatment of Protein Deficiency-induced Diseases
Diseases induced by severe protein-energy malnutrition can
be treated in three phases:
i. Resuscitation: For correction of dehydration, electrolyte
imbalance, acidosis, hypoglycemia, hypothermia, and the
treatment of infections.
142 Social Pharmacy
ii. Start of cure: Re-feeding, gradually working up the
calories (from 100 to 150 kcal per kg) and protein (to about
1.5 g per kg). There may be anorexia, and children often
have to be hand-fed, preferably in the lap of their mother
or a nurse. Potassium, magnesium, zinc, and a multi-
vitamin mixture are needed but iron should not be given
for the first week.
iii. Nutritional rehabilitation: After about three weeks if all
goes well the child has lost edema and the skin is healed.
The child is no longer ill and has a good appetite but he is
still underweight for age. It takes many weeks of good
feeding for catch-up growth to be complete. During this
stage, the child should be looked after in a convalescent
home or by its mother, who should, if possible, have been
educated about nutrition and provided with extra food.
Locally available foods are best.
c. Prevention of Protein-Energy Malnutrition
Five measures to prevent protein-energy malnutrition are being
actively promoted around the world.
a. Growth monitoring: WHO has devised a simple growth
chart-the Road to Health card. The mother should keep the
card and bring the child (plus the card) to the nearest clinic
regularly for weighing and advice.
b. Oral rehydration UNICEF formula of oral rehydration salt
(ORS) is saving many lives from gastroenteritis. It
includes:
Sodium chloride 3.5 g
Sodium bicarbonate 2.5 g
Potassium chloride 1.5 g
Glucose/sucrose 20 g/40 g
Clean drinking water, to make a solution 1 liter
c. Breastfeeding is a matter of life and death in a poor
community with no facilities for hygiene. Additional food,
prepared from locally available products, is needed from
four to six months of age.
d. Immunization should be done against measles, tetanus,
pertussis, diphtheria, polio, and tuberculosis.