Selasa, 12 April 2011


Harries-Benedict method for determining energy requirement;

Maleà BEE=66.47+(13.75xWt in Kg)+(5.0xHt in cm)-(6.76xAge in years)

FemaleàBEE=655.1+(9.56xWt in Kg)+(1.85xHt in cm)-(4.68xAge in years)

BEE is the theoretical caloric expenditure of the fasting, resting, non-stressed stat. it estimate a patients total caloric requirement BEE is multiplied by an activity factor (AF) and an injury factor (IF).

Total daily caloric requirement=BEE x AF X IF

AF = 1.2 for confined to bed

AF = 1.3 for ambulatory (mild 1.3, moderate 1.5, Heavy 1.7)



Non stressed ventilator dependant (other causes for ventilation extra-pulmonary causes)


Congestive heart failure


Minor surgery


Fever per 1°C


Skeletal trauma


Mild-moderate infection


Major abdominal/thoracic surgery


Multiple traums


Closed head injury


Stressed ventilator dependent (trauma, pulmonary failure)


Liver failure, cancer



Healthy diet;

CHO: 50 – 55%

Fat: not exceed 30%

10%, saturated, single bond only, solid at room temperature, animal fat shaham, dehn hurr, milk, dairy products, red meat sheep more than cows high in cholesterol and LDL (dangerous)

10% polysaturated, plant source mohadraj and germuhadraj

10% monosaturated olive oil (liquid at room temperature)

Olive oil is beneficial from healthy point of view to decrease cholesterol, LDL, TG, and increase HDL. The only beneficial naturally occurring oil is fish oil (oily fish better than flesh fish) (better twice a week)

Benefits, 1-Decrease effect of fatal post MI arrhythemia 2-Diet of choice in rheumatology and psoriasis, skin diseases, blood vessels and heart.

Do not exceed 300 mg cholesterol at any day

Serum cholesterol

Total cholesterol mg/dl

Harmful LDL mg/dl










Protein: 12 – 15% or 50 gram/day for females and 60 for males

Not to exceed double the RDA (100 Female, 120 male)

In meat 20% is protein

Cup of Milk= 8 grams protein full skim, 150 calories non-fat milk 80

In Yoghurt, there is lactose make calories less to 40 as low fat

Egg= 6 gram of protein 3 in yog and 3 in white in the egg 275 mg cholesterol in yog, so recommended to eat egg twice a week

Meat=20% protein

Beans= 14 - 16% protein except soya bean 40% protein

Animal protein contain all essential amino acids

Plant protein lack some essential amino acids

Protein and CHOà 4 Kcal for 1 gram

Fatà 9 Kcal for 1 gram

Mineral (NaCl) not exceed 6 grams/day for people with hypertension not exceed 2 – 3 grams.

Drink alcohol in moderation or not at all

Renal failure decrease protein intake from all sources

200 grams sugar (table sugar) = 770 Kcal (no protein, no fat)

199 carbohydrate, 1 fat


1-food items 9CHO, Fat, and protein)

2-Fiber contents of diet


4-Minerals and trace elements


6-Chemopreventive substances (chemicals naturally in food in shape of colours and flavours for the prevention of certain cancer.

Tomatoa contain material prevent ca prostate, called lycopene, kurkum contain material prevent ca stomach

Protein piece (lean, fat, beef, veal) of 85 gram à 15 – 30 Kcal (1 once, 28 grams)

19 gram protein

26 gram fat (10.8 saturated ; 11.4 monosaturated, 0.9 poly saturated, 0.72 cholesterol)

Lean beef, 61 gramà 150 Kcal 17 gram protein, 9 fat (saturated 3.6, mono 3.7, polyunsaturated 0.3, cholesterol 0.49)

Labm (kasera, fukoth) = lean and fat = 63 gram= 220 Kcal, 20 gram protein, 15 gram fat, 77 Mg cholesterol

Lamb lean only (zaned)= 48 gram, 135 Kcal, 17 gram protein, 59 Mg cholesterol


Allowed for 25 gram/day sugar in case he is normoglycemic normolipidic

(Spoon cup 8 grams of sugar)


Not need Insulin fructose 50%

Need insulin glucose 50%

Aim of diet management in type I DM and type II;

1-Regulate blood glucose and lipid level (achievement of biochemical normality)

2-Attain and maintain desirable body weight

3-Provide adequate nutrition (type I they are young so not to be stunted growth, achieve anthropometric normality)

4-Abolishing symptoms (thrust, polyuria, polydypsia)

Loaf breed= 454 gram; 1160 Kcal; 42 gram protein, 16 gram fat

Loaf bread slice=1 poun; slice=32 gram; 80 Kcal; 3 gram protein, 1 gram fat


Potato chips finger chips;



Chicke chest;

Chicken lamb stick;

Date; 83 grams; 230 Kcal, 2 gram protein, trace fat, 61 gram CHO, ca, ph, Iorn, K, Na, Vit A, thiamin, Niacin, No vit C

Nutritional problems of public health importance

1-Iron deficiency aneamia (IDA):

- 4 to 5 billion affected (66 – 88% of population are IDA

- 2 billions (30%) of aneamia

- In developing countries exacerbated by malaria and worm infestation

- Reduce capacity of individual and population

- Serious economical consequences and obstacles to national development

- IDA affect cognitive function (thinking) of primary school children

- Treatment can raise national productivity level by 20%

- Vulnerable à poorest, least educational, and they gain by its reduction

- Children health sequences include premature birth, LBW, infections, elevated risk of death, later physical and cognitive development impaired result in lower school performance

- Pregnantà aneamia contribute to 20% of all maternal deaths


1- Increase Iron intake;

· Supplementation of iron

· Iron rich diet

· Increase intake and absorption (vita C, stop suppressants like phytate ‘potatoes’, tyrine ‘tea’

· Fortification of food intake (flour, wheat, milk)

2- Infection control; Hook worm infestation, malaria, schistosomiasis

3- Improved nutritional status; Control major nutritional deficiencies, diet diverse (diversification) infection prevention

2-Vitamin A deficiency:

- Impact;

· Night blindness

· Maternal mortality

· Blindness; Xerophthalmia, dryness of eye, corneal opacity, softening of eye ball (keratomalacia), rupture of eye ball (kerato vertious)

- 100 to 140 million children are VAD

- An estimated 250 to 500 thousand VAD children become blind every year, half of them died in the first year of becoming blind ( because of lower immunity, persistent infection and other related nutritional problems as measles, ARI diarrhea..)

- 600 thousand women died from child-birth related causes, the vast majority of them from complications that reduced by better nutrition including VAD

- Leading cause of preventable blindness in children and raise susceptibility to death due to infection

- Problem in 118 countries in the world as VAD (Africa, SE Asia)

- WHO goals is the worldwide elimination of VAD and its tragic consequences (blindness, death, premature death)

- Short term intervention, proper feeding in infancy these backed up by long term sustainable solutions in order to combat VAD successfully

- Arsenal مستودع of well being weapons included a combination of breast feeding (natural source of VA) and VA supplementation with promotion of VA rich diet and food fortification

- VA supplementation for deficient children by periodic supply of VA is low cost high effective, decrease mortality by 3% and reduce by 50% of acute measles survival sufferers

- 50 000 IU twice (100 000 may reach 200 000) for children, then after 6 months repeated to all children (stay in liver up to 6 months)

- Food fortification and home gardens for vegetables (to use as cheap dietary fresh source of VA)

- Supplementation of daily requirement as 5 000 IU

- Higher doses of VA are teratogenic, should not be given to pregnant or future pregnancy (so it is better to be given at purperium period.. after delivery)


- Subclinical when serum retinol levels are <0.7 µmol/L and immunity and other physiological processes are impaired

- Clinical when there are ocular signs

- Recognition; at present there is no satisfactory field test to detect subclinical VAD. Serum retinol levels are used but are depressed by infection. The presence of any sign of xerophthalmia indicates clinical VAD. It is considered a public health problem when any of the following situations is present;

1- Among children aged <6 years;

· 1% have night blindness, or

· 0.5% have Bitot’s spots, or

· 0.01% have corneal xerosis and/or ulceration and/or keratomalacia, or

· 0.05% have xerophthalmia related corneal scars

2- 5% of pregnant women are night blind

3- The U5 mortality rate U5MR is >70%

- VAD is associated with an increased risk of transmitting HIV from mother to infant in the breast milk.

- Severe forms of the disease are often associated with other co-existing factors that may affect both levels of and demand for, retinol binding protein. These include energy nutrient malnutrition and infections.

- An association between measles and xerophthalmia has been reported. When the measles virus infects the conjunctiva and cornea, the epithelia are damaged, if there is insufficient vitamin A or retinol binding protein available for epithelial regeneration, xerophthalmia may develop.

- Also skin changes which include dryness and hyperkeratosis are also signs of VAD.

- VAD may play a role in the development of iron IDA among pregnant woman.


- The control of VAD can only be achieved through an improvement in the population dietary intake of retinol or B-carotene, this may require a change in food habits.

- Pregnant women should be advised to eat dark green leafy vegetables. This helps to build up stores of retinol in the fetal liver and should be educated about the importance of given such vegetables to their babies.

- A more specific short term measure is the oral administration of single high dose capsule containing 200 000 IU of VA to at risk children.

- In Iraq, we provide;

· A single dose of VA (50 000 IU) to young children at the age of 9 moths with the measles vaccine,

· At the age of 18 months another dose of VA (100 000 IU),

· And other prophylactic dose at the first year of primary school,

· Also a single dose of 200 000 IU usually provided to lactating mothers after delivery.

- Controlling measles and diarrhea also help to prevent VAD.


- Immediately on diagnosis 60 mg retinol (200 000 IU) should be given orally, or if there is vomiting or severe diarrhea (55 mg) retinol i.m. injection.

- The corneal lesions clear up within 48-72 hours.

- The VA preparation in a dose of 8-10 mg/day should be given for a month.

- Patients with ocular complications should be referred to ophthalmologist.


- The world most prevalent yet easily preventable cause of brain damage (proved by decrease cell and size of brain cells and decrease myelination of nerve cell)

- IDD affects over 740 million people (13% of world population), the 30% of the reminder are at risk

- IDD affect poor pregnant women, school children

- Problem in 130 developing countries

- IDD people may loss 15 IQ points

- 50 million people suffer from some degree of IDD disorders related to brain damage (cretinism)

- Cretinism à congenitalà divergenise squint, dwarf, goiter


- Dietary supplementation

- This is a geological problem of deficient iodine in soil only rich iodine source is sea food or sea weeds

- Only effective response is;

· food fortification

· iodine supplementation drops or capsules



- The basic function of iodine is to participate in the synthesis of the hormone thyroxine by the thyroid gland

- Risk associated with IDD; VA and Iron deficiencies are found universally throughout the developing world. While Iodine deficiency is largely restricted to those areas where iodine concentration is low in the soil and therefore in the water and in locally produced food.

- The presence of so-called goitrogenic substances in some local foods (which impair the body’s ability to utilize iodine) may increase the likelihood that deficiency signs will develop in areas that are low in iodine (cabbage, cauliflower, and beans).

Clinical features;

When an individual’s iodine supply is deficient, the thyroid gland becomes enlarged in an attempt to produce the quantities of the hormone that are needed by the body. This enlarged thyroid is called a goiter

- If the prevalence rate of goiter in a community is high, this is not, in itself a major public health problem. Endemic goiter consider as public health problem when there is a palpable enlargement of the gland in at least 30% of the adult population live in iodine deficient areas in underdeveloped countries of the world.

- The prevalence rate of endemic goiter is associated with the incidence of endemic cretinism and deaf mutism among newborns. If the prevalence rate of goiter among women of childbearing age exceeds 50%, as many as 10% of newborn children will have impaired mental and physical capacity as part of the congenital iodine deficiency syndrome.


Iodine deficiency is the single most common cause of mental retardation. It has different effects according to the severity of deficiency and stage of life cycle.

- In the 1st and 2nd trimesters of pregnancy, it causes varying degrees of irreversible damage to the developing foetus brain and nervous system, if severe it results in neurological cretinism (deafness and autism, severe mental retardation, squint, spastic paralysis)

- In neonates, it causes stillbirth, LBW, and occasionally, hypothyroid cretinism (baby feeds poorly, grows slowly, feels cold, is sleepy, has a rough dry skin and hoarse cry and is mentally retarded)

- In children and adults, it causes goiter and hypothyroidism (person feels cold easily, moves and thinks slowly, is lethargic, and may be sleepy, constipated or have dry skin), which affects school achievement and work output.


Iodine status of a community is assessed by indicators and classifications of IDD

- Normal: <5% prevalence of goiter in school age children+>100µg/L median urinary iodine in school age children and adults

- Mild IDD: 5 to 19% prevalence of goiter in school age children+ 50 to 99 µg/L median urinary iodine in school age children and adults

- Moderate IDD: 20 to 29% prevalence of goiter in school age children+ 20 to 49 µg/L median urinary iodine in school age children and adults

- Severe IDD: >30% prevalence of goiter in school age children+ <20 µg/L median urinary iodine in school age children and adults


1- Thyroid volume: Goiters are detected by;

· Inspection and palpation: A goiter is classified as: Grade 1à If palpable but not visible when neck in normal position. Grade 2à If visible with neck in normal position

· Ultrasound: which is more accurate especially where goiters are small

2- Urinary Iodine:


Treatment with iodine can reverse hypothyroidism and reduce the size of some goiters. IDD is prevented by;

- Fortifying food: Iodinization of salt is by far the most effective. In many countries it has been significantly decreases prevalence of IDD

- Fortifying water

- Giving oral high doses of iodine where iodized salt is not available and IDD is a public health problem

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