291

NUTRITION
CALORIFIC VALUE
1. Define calorific value. Pon Nov 2006
2. Give the calorific values of carbohydrates and fat. Pon May 2003; May
2005
1. Calorie is the unit of heat. One calorie represents the amount of heat required to
rise the temperature of one gram of water by l0 C. In medical practice, the energy
content is usually expressed in kilocalorie (kcal or C) which is equal to 1000
calories. 1 Cal (1 kcal) = 4.128 KJ
2. Caloric value is defined as amount of heat energy obtained by burning 1.0 gm of
the food stuff completely in the presence of O2.
3. Caloric value of different foodstuffs is determined in vitro in a special apparatus
called bomb calorimeter.
4. Caloric values:
a. Carbohydrate:
b. Fat:

4
9

c. Protein:
d. Alcohol:

4.2
7
BASAL METABOLIC RATE

1. Define BMR. What is the normal BMR of an adult? List 6 factors that affect
BMR. Pon Nov 2011
2. Define BMR. What is the normal values. List the factors affecting BMR. Pon
May 2010
3. Name two conditions which increase BMR. Pon May 2004
Man consumes energy to meet the fuel demands of the three ongoing processes in the
body.
1. Basal metabolic rate
2. Specific dynamic action
3. Physical activity
Basal metabolism: The basal conditions are as follows:
1. Person should be awake but at complete restboth physical and mental.
2. Person should be without food at least 12 to 18 hrs, i.e. in the postabsorptive
state.
3. Should be in recumbent/reclining position in bed.
4. Person should remain in normal condition of environment, i.e. at normal
temperature, pressure and humidity
Basal Metabolic Rate:

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1. Definition: The basal metabolic rate is the energy required by an awake

individual during physical, emotional and digestive rest.
2. It is the minimum amount of energy required to maintain life or sustain vital
functions like the working of the heart, circulation, brain function, respiration, etc.
The metabolic rate during sleep is less than BMR.
3. Resting metabolic rate (RMR) is the measure of energy required to maintain life or
vital functions. The subject is awake and nonfasting. It is approximately about 3%
higher than the BMR.
4. BMR is measured directly by the heat evolved, or indirectly by the volume of
oxygen consumed and carbon dioxide evolved per unit time.
Measurement of BMR:
1. subject is awake, physically and mentally at rest, and is in post absorptive state.
The BMR is calculated from oxygen consumption, calorific value and surface area.
1. Procedure: Benedict Roth method and Douglas bag (open circuit) methods
2. Benedict-Roth closed circuit method: the vol. of O consumed for 2-6 minutes under
basal conditions is measured by graphic recordings. One liter of O2 produces
4.825 cal. Heat produced in 6 minutes will be 4.825 x 10 x vol. of O2 in liters. It is
expressed as Cal/sq.m of body surface/hour
Normal values:
1. Adult male :

35-38 cal/sq.m/hr.

2. Adult female:

32-35

3. + or - 15 % of this could be taken as normal range.

4. Adult male 1600 cal/day female 1400/day is another simplified representation of
this value.
Factors affecting BMR:
1.

Body surface area is directly proportional to BMR.

2.

Sex: male is 5% higher BMR

3.

Infants and children have comparatively high BMR

4.

Exercise increase BMR

5.

Thyroxin increases BMR as seen in hyperthyroid state.

6.

Cold climate increases BMR

7.

Starvation leads to reduction in BMR as part of adaptation.

8.

Fever increases BMR; 10 % increase for 1.C

9.

BMR is elevated in infections.

10. In Eskimos it is higher.

Significance of BMR: it helps to calculate calorie requirement and diet calculation. It
helps to asses thyroid function.
SPECIFIC DYNAMIC ACTION
1. Define SDA. What is the SDA for each of the bulk element of the food? Pon
Nov 2010

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2. Define SDA. Mention its significance. Pon Nov 2006

1. Definition: The phenomenon of the extra heat production by the body, over and
above the cafculated caloric value, when a given food is metabolized by the body, is
known as specific dynamic action (SDA).
2. For eg. A person takes 25 gm of protein the energy produced should be 100 cal. But
the body liberates 130 calories. This extra calorie is the SDA of protein. Protein has
the highest value.
1. Cal of SDA is an activation energy needed for digestion, absorption, transport,
metabolism and other chemical reactions and is derived from previous food energy.
2. SDA values for each 100 calories:
Fat

Carbohydrate

113 cal
=

105 cal

Protein

130 cal

Mixed diet

110 cal

3. SDA for mixed diet : For a mixed diet, the SDA is not an additive value of different
foods but it is much less. The presence of fats and carbohydrates reduces the SDA of
proteins. Fats are most efficient in reducing SDA of foodstuffs. For a regularly
consumed mixed diet, the SDA is around l0%.
1. Significance of SDA:
a. An addition of 10 % cal should be added in calculating cal requirement to
compensate SDA.
b. Higher SDA for protein implies that it is not a good source of energy. But
consumption of a protein rich diet makes us feel warm and comfortable in cold
weather. This is due to the high SDA of proteins
a. Fat is a good source for its low SDA. However, excessive utilization of fat leads
to ketosis.
a. Hapatectomy abolishes SDA indicating major utilization is in Liver.
b. Consumption of high protein diet makes us feel warm.
GLYCEMIC INDEX
1. Glycemic index may be defined as the area under the blood glucose curve after the
ingestion of a food compared with the area under the blood glucose curve after
taking the same amount of carbohydrate as glucose. lt is expressed as percentage.
2. The glycemic index of a complex carbohydrate (i.e. starch) is lower than a refined
carbohydrate (eg. glucose). This is explained on the basis of slow digestion and
absorption of complex carbohydrates.
3. The glycemic index of carbohydrateis lower when it is combined with protein, fat or
fiber.
4. Low glycemic index foods usually have higher satiety value and may be helpful in

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limiting the caloric intake. Nutritionists are of the opinion that foods with high fiber
content and low glycemic index should be preferred for consumption
5. Examples of glycemic index:
1. Glucose:

100

2. Bread, rice:

70-80

3. Banana, potato

60-70

4. Orange; apple

40-45

5. Lce cream, milk

35-40
DIETARY FIBER

The unavailable or indigestible carbohydrate in the diet is called dietary fiber.

Beneficial effects of fibers:
1. Dietary fiber is necessary to maintain the normal motility of gastrointestinal tract.
2. Diet rich in fiber improves bowel motility, prevents constipation.
3. Fiber adsorbs large quantities of water and also the toxic compounds produced by
intestinal bacteria that lead to increased fecal mass and its easier expulsion.
4. The lower incidence of cancers of gastrointestinal tract (e.g. colon and rectum) in
vegetarians compared to non-vegetarians is attributed to dietary fiber.
5. Fiber improves glucose tolerance by the body. This is mainly done by a diminished
rate of glucose absorption from the intestine.
6. Fiber decreases the absorption of dietary cholesterol from the intestine. Further,
fiber binds with the bile salts and reduces their enterohepatic circulation. This
causes increased

degradation of cholesterol to bile salts and its disposal

from the body.

7. The beneficial effect is more with soluble fiber present in vegetables and only a
diet having plenty of vegetables and green leaves will have the desired effect.
Requirement:
Fiber requirement is about 30 g/day. The inclusion of fiber rich food in weight
reducing diets is found to be helpful, since it provides a feeling of fullness without
consumption of excess calories.
Sources: Fruits, Leafy vegetables, vegetables, whole-wheat legumes, rice bran etc.
Adverse affects of fiber:
a. Digestion and absorption of protein are adversely affected.
b. The intestinal absorption of certain minerals (e.g. Ca, P, Mg) is decreased.
c. Intestinal bacteria ferment some fibers, causing flatulence and often
discomfort
ESSENTIAL FATTY ACIDS
The unsaturated fatty acids which the body cannot synthesize and, therefore,

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must be consumed in the diet are referred to as essential fatty acids (EFA).
Functions of EFA
1. Essential fatty acids are the structural components of biological membranes.
2. Participatei n the transporta nd utilization of cholesterol.
3. Prevent fat accumulation in the liver.
4. Required for the synthesis of prostaglandins
5. Maintain proper growth and reproduction of the organisms
Deficiency of EFA
1. Essential fatty acid deficiency is associated with several complications. These
include impairment in growth and reproduction, increased BMR and high turnover
of phospholipids.
2. The EFA deficiency is characterized by a scaly dermatitis on the posterior and
lateral parts of limbs and buttocks, referred to as phrynoderma or toad skin.
3. Poor wound healing and hair loss is also observed in EFA deficiency.
EFA content of foods
1. The essential fatty acids, also called polyunsaturated fatty acids (PUFA), are
present in vegetable oils and fish oils.
2. The sources include sunflower oil, cofton seed oil, corn oil, soyabean oil etc. The
fat of animal origin (exception-fish), contain less PUFA e.g. butter, fat of meat, pork
and chicken.
Dietary intake of EFA
1. 30% of the dietary fat should contain PUFA.
2. Excess PUFA, unless accompanied by antioxidants (vitamin E, carotenes) is
injurious to the cells due to the overproduction of free radicals.
PROTEINS
COMPLETE PROTEIN
1. What do you mean by complete protein? Give example. Pon Nov 2006
1. A complete protein contains an adequate amount of all of the essential amino acids
that should be incorporated into a diet.
2. Animal proteins are complete proteins as compared to those of vegetable proteins
(Incomplete proteins).
3. Whole egg and milk proteins, specially Lactalbumin rank highest in this respect and
they contain the highest percentages of the essential amino acids.
4. Meat, fish, poultry and glandular tissues occupy next position in the scale. In the
same class, are also yeast and soyabean.
5. Cereals, legumes (peas, beans, etc) and nuts are generally poor because they lack
some essential amino acids and thus they are incomplete proteins and are of poor
quality.

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NITROGEN BALANCE
1. What do you mean by the term nitrogen balance? Which are the
conditions in which positive nitrogen balance is observed? Pon Apr 2002
1. A normal healthy adult is said to be in nitrogen balance, because the dietary intake (I)
equals the daily loss through urine (U) feces (F) and skin (S).
I=U+F+S
2. When the excretion exceeds intake, it is negative nitrogen balance. When the
intake exceeds excretion, it is a state of positive nitrogen balance.
3. Nitrogen balance can be measured by calculating the dietary intake of protein
nitrogen (16% of the weight of protein) and measuring the daily excretion.
4. Factors Affecting Nitrogen Balance
a. Growth: During the period of active growth, a state of positive nitrogen balance
exists. On an average when a person gains 5 kg, about 1 kg proteins are added to
the body.
b. Hormones: Growth hormone, insulin and androgens promote positive nitrogen
balance, while corticosteroids cause a negative nitrogen balance.
c. Pregnancy: A pregnant woman will be in a state of positive nitrogen balance
due to the growth of fetus.
d. Acute illness: Negative nitrogen balance is seen in subjects immediately after
surgery, trauma and burns.
e. Chronic illness: Malignancy, uncontrolled diabetes mellitus and other
debilitating diseases show negative nitrogen balance.
f.

Convalescence: convalescence after an illness or surgery will be in positive

nitrogen balance, due to active regeneration of tissues.

g. Protein deficiency: The deficiency of even a single essential amino acid can
cause negative nitrogen balance. Prolonged starvation is another important
cause.
5. Maintenance of Nitrogen Balance
a. Obligatory nitrogen loss is 3.5 g of N/day for a 65 kg person due to urinary,
fecal and cutaneous loss. This could be equivalent to 22 g of protein.
b. Protein requirements for growth. This is applicable in the case of infants,
children, adolescents, pregnancy, lactation and convalescence. As growth
stops, protein requirement also decreases.
6. Positive nitrogen balance:
a. This is a state in which the nitrogen intake is higher than the output. Some
amount of nitrogen is retained in the body causing a net increase in the body
protein.
b. Positive nitrogen balance is observed in growing children, pregnant women or
during recovery after serious illness.
7. Negative nitrogen balance:
a. This is a situation in which the nitrogen output is higher than the input. The

297

result is that some amount of nitrogen is lost from the body depleting the body
protein.
b. Prolonged negative nitrogen balance may even lead to death. This is
sometimes observed in children suffering from kwashiorkor or marasmus.
c. Negative nitrogen balance may occur due to inadequate dietary intake of
protein (deficiency of even a single essential amino acid) or destruction of
tissues or serious illness. In all these cases, the body adapts itself and
increases the breakdown of tissue proteins causing loss of nitrogen from the
body.
8. Other factors influencing nitrogen balance
Hormones : Growth hormone and insulin promote positive nitrogen balance while
corticosteroids result in negative nitrogen balance.
Disease states: Cancer and uncontrolled diabetes cause negative nitrogen
balance.
BIOLOGICAL VALUE (BV) OF PROTEIN
1. Define biological values of protein. Pon May 2010
1. It is the ratio between the amount of nitrogen retained and nitrogen absorbed during
a specific interval.
BV =

Retained nitrogen X 100

Absorbed nitrogen

2. For the measuremenot f BV, the experimental animals, namely weaning albino rats
are chosen Suppose 127 mg of a particular protein was consumed by a rat in a day
and 4 mg is recovered in feces and 24 mg is seen in urine. Then
Amount ingested =

127 mg

Amount absorbed = 127 4

Amount retained =

123 24

= 123 mg
= 99 mg

Therefore BV = 99/123 X 100

= 81%

3. Biological value can be calculated by the following formula:

BV = (N absorbed- N lost in metabolism) x 100
N absorbed
4. The BV for different protein sources:
a. Egg protein:

94

b. Milk protein:

84

c. Fish:

85

d. Meat:

75

e. Rice:

68

f.

58

Bengal gram:

g. Soya

65

5. The biological value provides a reasonably good index for the nutritive value of

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proteins.
6. The drawbacks: It cannot take into account the nitrogen that might be lost during the
digestion
7. Net protein utilization (NPU) is a better nutritional index than biological value, since it
takes into account the digestibility factor. The experimental procedure for NPU is
similar to that of BV. Net protein utilization can be calculated as
NPU = Nitrogen retained x 100
Nitrogen ingested
MUTUAL SUPPLEMENTATION OF PROTEINS
1. What do you mean by the term mutual supplementation of proteins? Pon
Apr 2002
2. What is the nutritional basis for ingesting combination of cereals and
pulses? Pon Dec 2003
1. Limiting amino acids: Certain proteins are deficient in one or more essential
amino acids. If this protein is fed to a young rat as the only source of protein, it fails
to grow. This amino acid is said to be the limiting amino acid. Limiting amino acid is
that which limits the weight gain when a protein is supplied to an animal
2. The animal proteins are superior in their nutritive value compared to the proteins of
vegetable origin. But some of the essential amino acids are limiting in vegetable
proteins. For instance, rice and wheat proteins are limiting in lysine and threonine
while the protein of Bengal gram is limited in sulfur-containing amino acids
(methionine and cystine).
3. This problem can be overcome by supplementation of the essential amino acids in
one food to the other that lacks such essential amino acids. This phenomenon is
referred to as mutual supplementation.
4. Example: diet with cereals (wheat, rice) is taken along with pulses (dal). The
limitation of lysine and threonine in cereal proteins is overcome by their
supplementation from dal proteins. Simultaneously, the limitation of sulfur containing
amino acids in dal is also compensated by the cereals, which are rich in them.
5. The principle of mixed diet takes care to supply adequate quantities of essential
amino acids to the people subsisting on pure vegetarian diets. lt has to be
remembered that the effect of mutual supplementation in proteins is best observed
with the same meal or on the same day.
PRESCRIPTION OF DIET
1. Calculate the daily energy requirement of a 20 year old sudent. Pon Nov
2011
Energy requirement of MAN or calculation of your veg. diet
General Principles:

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1. Ideal body weight:

i. Male of 153 cm height = 48 kg (+ or - 1.25 kg for every cm)
ii. Female of 153 cm height = 45 kg (+ or - 1 kg for every cm)
2. Protein requirement: 1 gm / kg
3. Calorie requirement: 30 to 35 Kcal / kg of expected (not actual) body wt
4. Specific dynamic action: Extra energy is to be supplied to account for SDA.
5. Balanced diet means to contain 60% carbohydrate; 20% fat and 20 % proteins
Step 1:
60 kg male; require 60x30 = 1800 Kcal + 10 % for SDA = 180; total requirement
is rounded of to 2000 Kcal.
Step 2:
Protein: 1 gm/kg to provide (60 gm x 4 C)

240 Kcal

60 gm

Fat to provide (20% of 1760; 2000 minus 240 = 1760)

350 kcal

350/9 = 35

gm
Carbohydrate to provide 1410 C (1760 - 350 = 1410/4= 320) 1400 kcal

1400/4=

350 gm
Calcium

400 mg

Iron

25 mg

Step 3:
Composition:

cereals and pulse ratio is 5:1

Cereals

350 gm

Pulses

75

gm

Oil

40 ml

Milk

250 ml

Leafy vegetables

200 gm

Sugar

25 gm

Step 4:
Servings:
Proteins in gms
Energy in Kcal

in gms

Break fast:

2 chappatis or 2 idlis
100 ml milk

CH2O

=
=

50 gm channa

30

3
=

140

5
12

60
30

170

Lunch:
100 gm Rice

10

75

350
50 gm Bengal gram
1 Banana

=
=

100 gm Green leafy veg

12

30
10

170
50

20

30

140

Dinner:
2 chappatis or 2 idli

300

50 gm rice

35

175

50 gm green gram

12

30

170

100 ml milk

60

1 Banana

10

50

50 gm oil

10

10 gm Sugar
100 gm Green leafy veg

Total

450
40
4

73

303

20
2065

PROTEIN CALORIE MLNUTRITION

1. What is Kwashiorkor? What are the changes found in the plasma of a
child with this disorder. Pon Nov 2007KWASHIORKOR
1. MOST COMMON NUTRITIONAL PROBLEM IN DEVELOPING COUNTRIES.
2. Predominantly affect children; incidence from 20 to 50 ?
3. Malnutrition is a wide spectrum; at one end marasmus and at the other extreme is
kwashiorkor.
4. Marasmus: it results from continued deprivation of energy to a greate extent and
protein to a lesser extent leading to wasting , wise man appearance , weight loss
and depletion of muscle. There is no significant edema.
5. Kwashiorkor:
1. Kwashiorkor is associated with premature abandonment of breastfeeding,
which typically occurs

when a younger sibling is born, displacing the

older child from the breast.

2. So children with kwashiorkor tend to be older than those with marasmus.
3. Kwashiorkor may also result from an acute illness, often gastroenteritis or
another infection in a

child who already has PEU.

4. A diet that is more deficient in protein than energy may be more likely to cause
kwashiorkor than

marasmus.

5. In kwashiorkor, cell membranes leak, causing extravasation of intravascular

fluid and protein,
resulting in peripheral edema .
6. Biochemical alterations:
1.

Metabolic rate is decreased.

2.

albumin level in serum is very low (2 g/dl) in kwashiorkor and slightly low in

marasmus.
3.

Ig G is increased due to infections.

4.

Liver undergoes fatty changes due to decreased lipoprotein synthesis.

5.

Hypoglycemia is common.

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6.

Hypokalemia is associated with dehydration.

7.

Hypomagnesemia is often seen.

7. Treatment:
1.

a planned diet manipulation by providing 150-200 Kcal and 3-4 gm protein per kg

body weight under

supervision is the ideal treatment. A mixture of 3 parts of

vegetable proteins and 1 part of milk protein

8.

is often used.

Sequelae: relapse is common; intellectual capacity may be reduced permanently.