UNIT ICM 2118: NUTRITION AND DIETETICS

COURSE DESCRIPTION

1. Basic nutrition

2. Basic principles of nutrition and dietetics

3. Nutrient types, sources and roles in the body digestion and absorption.

4. The objectives of diet therapy

5. Factors influencing nutrition, such as religious, cultural economic knowledge and social.

6. Food security accessibility, availability and utilization.

7. Nutrition assessment; direct (individual) and indirect (community) methods; importance and
disadvantages.

8. Nutrition requirement in various life cycles; infancy early childhood, adolescence, early adulthood and
late adulthood; nutrition in various physiological states-pregnancy and lactation.

9. Malnutrition states and eating disorders; causes prevalence; various malnutrition to include protein
energy malnutrition vitamin deficiencies mineral deficiencies, malnutrition and infections overweight and
obesity; management of various malnutrition states.

10. Nutrition and dietary principles in recovery of any chronic disease of your choice
(Assignment). Should be typed in times roman font 12.

Continous assessment tests assignment (30%) and end of semester examinations (70%)

a) Course Textbooks
1. Hall, W. S. (2010). Nutrition and Dietetics. Nabu Press. ISBN-13: 978-1-146-53583-0,
ISBN: 1-146-53583-X.
2. Hall, W. S. (2004). A Manual for Students of Medicine, Trained Nurses and Dietitians.
Kessinger Publishing. ISBN-13: 978-1-4179-6157-3, ISBN: 1-4179-6157-0.
3. Gandy, J., Madden, A. and Holdsworth, M. (2012). Oxford Handbook of Nutrition and
Dietetics. Oxford University Press. ISBN-13: 978-0-19-958582-3, ISBN: 0-19-958582-2.
b) Course Journals
1. Journal of the Academy of Nutrition and Dietetics. Elsevier. ISSN: 22122672.
2. Journal of Human Nutrition and Dietetics. Wiley-Blackwell. ISSN: 09523871, 1365277X.
3. World Review of Nutrition and Dietetics. S. Karger AG.ISSN: 16623975, 00842230.
c) Reference Textbooks
1. Ansari, S. (2012). Nutrition and Dietetics. Arise Publishers & Distributors. ISBN-13: 978-93-
81031-05-6, ISBN: 93-81031-05-3.
2. Sharma, A. K. (2012). Human Nutrition and Dietetics. Kaveri Book. ISBN-13: 978-93-5030-
060-2, ISBN: 93-5030-060-5
3. Davidson, S., Passmore, R. and Brock, J. F. (1972). Human Nutrition and Dietetics.
Churchill Livingstone. ISBN-13: 978-0-443-00947-1, ISBN: 0-443-00947-3.
d) Reference Journals
1. Nutrition and Dietetics. Wiley-Blackwell. ISSN: 17470080, 14466368.
2. Journal of Nutrition. American Society for Nutrition. ISSN: 00223166, 15416100.
3. Nutrition. Elsevier Inc. ISSN: 08999007, 18731244.
INTRODUCTION TO NUTRITION AND CLINICAL DIETETICS

WHAT IS NUTRITION?

Nutrition

It is a science that encompasses all the interactions that occur between living organisms and
food. Nutrition is how food affects the health of the body. Food is essential—it provides vital
nutrients for survival, and helps the body function and stay healthy.

Nutrient

Is a substance that provides nourishment essential for the maintenance of life and for growth.

Diet

This refers to the kinds of food that a person, animal, or community habitually eats.

Normal diet

It is one that supply all the nutritional needs of a normal healthy individual including all nutrients
carbohydrates, proteins, fat, vitamins, mineral and water.

Basic principles of nutrition and dietetics

a. Adequacy in all nutrients

An adequate diet provides all nutrients to meet the recommended nutrient intake of healthy
people.

b. Balance of foods and nutrients in the diet

This means not over consuming any one food. The art of balance involves the use of enough
but not too much or too little of each type of the seven food groups for example use some
meat or meat alternatives for iron, use some milk or milk products for calcium and save some
space for other foods. The concept of balance encompasses proportionality both between and
among the groups.

c. Nutrient density

This is the relative ratio obtained by dividing a food's contribution to the needs for a nutrient
by its contribution to calorie needs. This is assessed by comparing the vitamin and mineral
content of a food with the amount of calories it provides. A food is nutrient dense if it
provides a large amount of nutrient for a relatively small amount of calories.

d. Energy density

This is the amount of energy in kilocalories in a food compared with its weight. Examples of
energy dense foods are nuts, cookies, and fried foods. Low energy density foods include
fruits, vegetables and any food that incorporates a lot of water during cooking. They
contribute to satiety without giving many calories.

e. Moderation in the diet

This mainly refers to portion size. This requires planning the entire day’s diet so as not to
under/over consume any one food. In planning the diets, the goal should be to moderate
rather than eliminate intake of some foods

f. Variety in food choice

This means choosing a number of different foods within any given food group rather than
eating the same food daily. People should vary their choices of food within each class of food
from day to day. This makes meals more interesting, helps to ensure a diet contains sufficient
nutrients as different foods in the same group contain different arrays of nutrients and gives
one the advantage of added bonus in fruits and vegetables as each contain different phyto
chemicals.
Carbohydrates

Carbohydrates are the most abundant organic compounds in the universe. They include
the structural parts of plants in the form of cellulose as well as stores of starches and
sugars. The sun is the ultimate source of energy for living organisms. By an exceedingly
complex process known as photosynthesis, the energy of the sun is utilised by
chlorophyll (the green colouring matter in leaves) to synthesize carbohydrate from
carbon dioxide in the air and water from the soil. This is probably the most important
reaction for the continuance of life because the energy stored in the leaves, stems,
roots and seeds is used in turn by animal species
6 CO2 + 6 H2O + light energy = C6H12O6 + 6 O2.
Composition
Chemically, all carbohydrates are composed of the elements Carbon (C), Hydrogen (H)
and Oxygen (O). Like water, they have twice as many hydrogen atoms as oxygen
atoms. Each particular carbohydrate has a distinct chemical arrangement which gives
variation to their sweetness and other physical properties.
With regard to dietary significance, starches and sugars account for more than half of
the caloric intake around the world.

Classification of Carbohydrates
Carbohydrates are classified into two:

A. Simple carbohydrates (Simples sugars)

B. Complex carbohydrates (Starches and fibre)
A. Simple Carbohydrates

Simple carbohydrates include monosaccharide and disaccharides referred to as sugars

Monosaccharides
These are the simplest form of carbohydrates, which do not require further hydrolysis as
they are composed of one [mono] carbohydrate unit.
There are three main monosaccharides which are most significant nutritionally i.e.
glucose, galactose and fructose. These have the same empirical formula, C6H12O6.
Monosaccharides are readily absorbed from the intestinal wall into the bloodstream. In
their groupings, they differ in the arrangement of the carbon atoms and are distinctive in
their physical properties, such as solubility in water and sweetness.

a. Glucose

Also known as dextrose, grape sugar or corn sugar, is less sweet than cane sugar and
is soluble in either hot or cold water. It is found in sweet fruits such as grapes, berries
and oranges and in some vegetables such as sweet corn and carrots.
It is also prepared commercially as corn syrup or in its crystalline form by the hydrolysis
of starch with acids.
Glucose is the chief end product of the digestion of disaccharides and polysaccharides.
It is the form in which carbohydrates circulate in the blood and which is utilized by the
cell for energy.

b. Fructose

Fructose, also known as levulose or fruit sugar is a highly soluble sugar that does not
readily crystallize. It is much sweeter than cane sugar and is found in honey, ripe fruits,
and some vegetables. It is also a product of the hydrolysis of sucrose.

c. Galactose

This is not found free in nature, as its only source is the hydrolysis of lactose. When
combined with glucose, the milk sugar, lactose, is formed.

Disaccharides
Disaccharides are double sugars [Cl2H22O11] that result when two units of hexoses
[monosaccharides] are combined together. They are water soluble, diffusible, and
crystallisable and vary widely in their sweetness.
They are split to simple sugars by acid hydrolysis or by digestive enzymes. The three
disaccharides which are important in nutrition are sucrose, maltose and lactose.

a. Sucrose
This is the familiar table sugar, which is found in cane or beet sugar, brown sugar,
sorghum, molasses, and maple sugar. Many fruits and some vegetables contain small
amounts. It is mainly used in cookery. Sucrose is formed from one unit of glucose and
one unit of fructose.
Glucose + Fructose = Sucrose.

b. Lactose,

Lactose or milk sugar is produced by mammals and is the only carbohydrate of animal
origin that is significant in the diet. It is especially an important source of energy for
infants when on a milk diet. It is about one sixth as sweet as sucrose and dissolves
poorly in cold water. The concentration of lactose in milk varies from 2 to 8 per cent,
depending on the animal species. Lactose is formed from one unit of glucose and one
unit of galactose.
Glucose + Galactose = Lactose.

c. Maltose

Maltose or malt sugar is found in cereals e.g. barley and is formed during germination. It
is an intermediate product in the hydrolysis of starch and only occurs in very small
amounts in foods. Maltose is produced in the processes of malting and fermentation of
grains and is present in beer and malted break-fast cereals. It is also used with dextrin
(as thickening agent in foods) as the source of carbohydrate for some infant formulas.
Maltose is formed from two units of glucose.

B. Complex Carbohydrates or Polysaccharides:

These are made of long chains of many sugar molecules. They are insoluble in water
and are digested with varying degrees of completeness.
They do not taste sweet because of the way their sugar molecules are arranged. Those
that are significant in nutrition include starch, dextrin, glycogen and fibre.

a. Starch
Starch is the storage form of carbohydrates in plants and is found in large amounts in
cereals, root vegetables, and dry legumes. It is composed of several glucose molecules
(hundreds to thousands) which may be arranged in one long straight chain (amylose),
or in a shorter branched chain (amylopectin). Most starches contain 15% –30%
amylose.
Starch is the chief form of carbohydrates in the diet. Different food sources have
different physical properties (solubility, thickening power and flavour), based on the ratio
of amylose to amylopectin, the starch granules are encased in a cellulose - type wall
and are distinctive in size and shape for each source.
When cooked in moist heat, the starch granules absorb water and swell, and the walls
of the cell rupture, thus permitting more ready access by the digestive enzymes.
Amylopectin has colloidal properties which cause a starch-water mixture to thicken
when
heat is applied.

b. Dextrins

These are intermediate products that form when starch is subjected to enzyme action
(digestion) or heat (as in cooking or toasting) and consist of shorter chains of glucose
units.
Dextrins are more soluble and slightly sweeter than starch, but do not have the
thickening power of starch.

c. Glycogen

Glycogen or animal starch is similar in structure to the amylopectin of starch, but

contains many more branched chains of glucose. Glycogen is the form in which
carbohydrates are stored in the body. It is synthesized from glucose and stored in the
liver and muscle tissues as energy reserve. When energy is required, it is converted to
glucose.

d. Fibre:
Cellulose and hemicellulose cannot be hydrolyzed by enzymes of the human digestive
tract, so they yield no energy and are excreted in the faeces. Tough fibres including
seeds, skins, and structural parts of plant foods are broken into smaller particles,
whereas the more tender fibres of young plants may be partially disintegrated by
bacterial action within the large intestine. The cooking of foods also softens fibres and
partially disintegrates them.
3.3 Sources Of Carbohydrates
Cereals – These include Maize, Wheat, Rice, Millet and all their products
Legumes – All varieties of beans, Peas, Green grams, Groundnuts
Roots & Tubers – Potatoes, Yams, Bananas, Cassava, Arrow roots, sweet potatoes
Fruits & Vegetables – All types of fruits and starchy vegetables and also cane sugar

Added sugar in foods and drinks with empty calories

Functions of Carbohydrates

a. Energy Source:

Carbohydrates are the most economical and efficient source of energy. Each gram of
carbohydrate when oxidised yields, on the average, 4 calories (E.g. one tablespoon of
sugar contains 12 g of carbohydrate and hence yields 48 kcal (12 x 4 = 48 kcal). Some
carbohydrate in the form of glucose will be used directly to meet immediate tissue
energy needs, a small amount will be stored as glycogen in the liver and muscles, and
some will be stored as adipose tissue for later conversion to energy. Glucose is the sole
form of energy for the brain and nervous tissue and must be available moment by
moment for the functioning of these tissues. Any failure to supply glucose or the oxygen
for its oxidation rapidly damages the brain.

Glycogen is the storage form of carbohydrate in the body. At any given time about 100
gm glycogen can be stored in the liver and is available to replenish the glucose level of
the blood. Cardiac, smooth, and skeletal muscles contain about 200 to 250 gm glycogen
that is instantly available within the muscle but is not available for regulation of the blood
sugar level. Together, muscle and liver glycogen if completely used could meet no more
than half the day's energy need.

b. Protein-sparing action:

The body will use carbohydrate preferentially as a source of energy when it is

adequately supplied in the diet, thus sparing protein for tissue building. Since meeting
energy needs of the body takes priority over other functions, using adipose and protein
tissues will make up any deficiency of calories in the diet.

c. Regulation of fat metabolism:

Some carbohydrate is necessary in the diet so that the oxidation of fats can proceed
normally. When carbohydrate is severely restricted in the diet, fats will be metabolised
faster than the body can take care of the intermediate products. The accumulation of
these incompletely oxidised products leads to ketosis. Carbohydrate must be almost
completely lacking in the diet for acidosis to occur under normal conditions, but it is
common in uncontrolled diabetes mellitus.

d. Role in gastrointestinal function:

Several regulatory functions have been attributed to lactose.

 Lactose promotes the growth of desirable bacteria in the small intestine. Some of
these bacteria are useful in the synthesis of certain B complex vitamins.
 Lactose also enhances the absorption of calcium. It is undoubtedly no accident of
nature that milk, which is the out-standing source of calcium, is also the only dietary
source of lactose.
 Cellulose, hemicellulose, and pectins yield no nutrients to the body. These
indigestible substances aid in the stimulation of the peristaltic movements of the
gastrointestinal tract, and by absorbing water gives bulk to the intestinal contents
and reduces the length of time food wastes stay in the colon.

e. Component of various body compounds:

Structurally, carbohydrates account for a very small part of the body weight.
Nevertheless, monosaccharides are vitally important constituents of numerous
compounds that regulate metabolism. Examples of these are:
 Glucuronic acid, which occurs in the liver and is also a constituent of a number of
mucopolysaccharides.
 Hyaluronic acid, a substance found in the fluid that lubricates the joints and the
vitreous humour of the eyeball.
 Heparin, the naturally occurring anticoagulant in blood.
 Chondroitin sulphates found in skin, tendons, cartilage, bone, and heart valves.
 Immunopolysaccharides as part of the body's mechanism to resist infections.
 Galactolipins as constituents of nervous tissue.
 Deoxyribonucleic acid (DNA) and ribonucleic acid (RNA), the compounds that
possess and transfer the genetic or hereditary characteristics of the cell.
 Glycosides as components of steroid and adrenal hormones.
 Keratan sulphate, present in hard structures like fingernails

Dietary Fiber
Dietary fiber, also known as roughage or bulk, includes the parts of plant foods the body
can't digest or absorb. Unlike other food components, such as fats, proteins or
carbohydrates – which the body breaks down and absorbs – fiber isn't digested by the
body. Instead, it passes relatively intact through the stomach, small intestine and colon
and out of the body.
Fiber is commonly classified as soluble, which dissolves in water, or insoluble, which
doesn't dissolve.
Soluble fiber. This is the type of fiber that dissolves in water to form a gel-like material.
It can help lower blood cholesterol and glucose levels. Soluble fiber is found in oats,
peas, beans, apples, citrus fruits, carrots, barley and psyllium.
Insoluble fiber. This is the type of fiber that promotes the movement of material
through the digestive system and increases stool bulk, so it can be of benefit to those
who struggle with constipation or irregular stools. Whole-wheat flour, wheat bran, nuts,
beans and vegetables, such as cauliflower, green beans and potatoes, are good
sources of insoluble fiber. Most plant-based foods, such as oatmeal and beans, contain
both soluble and insoluble fiber.

However, the amount of each type varies in different plant foods. To receive the
greatest health benefit, eat a wide variety of high-fiber foods.

Other Classifications of Fibre:

In addition to being classified according to their solubility, they can also be classified
according to other physical properties that affect their function and nutrient absorption.
The physical properties include:
-Water-holding capacity: the capacity to capture water like a sponge, thus swelling
and increasing the bulk of the intestinal contents.
-Viscosity: the capacity to form viscous, gel-like solution
-Cation - exchange capacity: the ability to bind minerals.
-Bile-binding capacity: the ability to bind to bile acids.
- Fermentability: the extent to which bacteria in the GI tract can break down fibers to
fragments that the body can use.
Generally, fibers are often described as non - starch polysaccharides and they include
cellulose, hemicelluloses, pectins, gums and mucilages. Fibers also include some
non-polysaccharides such as lignins, cutins and tannins.
Even though most are polysaccharides, fibers differ from starches in that human
digestive enzymes cannot break down the bonds between their monosaccharides.

a. Cellulose:

Cellulose is the most abundant organic compound in the world, comprising of about 50
per cent of the carbon in vegetation. This is the primary constituent of plant cell walls
and therefore, occurs in all vegetables, fruits, and legumes. Like starch, cellulose is
composed of glucose molecules connected in long chains. Unlike starch, however, the
chains do not branch, and the bonds linking the glucose molecules together resist
digestion by human enzymes. Ruminants are able to utilize cellulose for energy
because of the presence of specific enzymes in their rumen.

b. Hemicelluloses:

These are the main constituents of cereal fibers. They are composed of various
monosaccharide backbones with branching side - chains of monosaccharides.
The many backbones and side chains make the hemicelluloses a diverse group. Some
are soluble, while others are insoluble.
The most common backbone monosaccharides are xylose, mannose and galactose.
The common side chains are arabinose, glucuronic acid and galactose.

c. Pectins:

All pectins consist of a backbone derived from carbohydrates with side chains of various
monosaccharides. They are commonly found in vegetables and fruits (especially citrus
fruits and apples). Pectins may be isolated and used by the food industry to thicken
jelly, keep salad dressings from separating and otherwise control texture and
consistency. They are able to perform these functions because they readily form gels in
water.

d. Gums and mucilages:

When a plant is cut, it secretes gum from the site of the injury. Like the other fibers,
gums are composed of various monosaccharides and their derivatives. Gums such as
gum Arabic are used as additives by the food industry. Mucilages are similar to gums
in structure. They include guar and carrageenan, which are added to foods as
stabilisers.

e. Lignin:
This nonpolysaccharide fibre has a three-dimensional structure that gives it strength.
Due to its toughness, few of the foods that people eat contain much lignin. It occurs in
the woody parts of vegetables such as carrots and the small seeds of fruits such as
strawberries.

Several indigestible polysaccharides have useful properties in food processing.

Pectins, for example, found in ripe fruits, have the ability to absorb water and to form
gel, a property utilized in making fruit jellies. Agar is obtained from seaweed and is
useful for its gelling properties. Carrageen (Irish moss) and alginates from seaweed
are often used to enhance the smoothness of foods such as ice cream and evaporated
milk.

Sources of Fiber:

a. Soluble fiber is found in varying quantities in all plant foods, including:

 Legumes (peas, soybeans, lupins and other beans)

 Oats, rye, chia, and barley
 Some fruits (including figs, avocados, plums, prunes, berries, ripe bananas, and
the skin of apples, quinces and pears)
 Certain vegetables such as broccoli, carrots, and Jerusalem artichokes
 Root tubers and root vegetables such as sweet potatoes and onions (skins of
these are sources of insoluble fiber also)
 Psyllium seed husks (a mucilage soluble fiber) and flax seeds
 Nuts, with almonds being the highest in dietary fiber

b. Insoluble fiber include:

 Whole grain foods

 Wheat and corn bran
 Legumes such as beans and peas

 Nuts and seeds

 Potato skins
 Lignins
 Vegetables such as green beans, cauliflower, zucchini (courgettes), celery, and
nopal
 Some fruits including avocado, and unripe bananas
 The skins of some fruits, including kiwi fruit, grapes and tomatoes

Digestion of Carbohydrates

The ultimate goal of digestion of sugars and starches is to dismantle them into small
molecules, mainly glucose, that the body can absorb and use. The large starch
molecules require extensive breakdown but the disaccharides only need to be
hydrolysed once. This is accomplished by enzymes of the digestive juices.

The initial splitting begins in the mouth. The final splitting and absorption occur in the
small intestine, while the conversion to a common energy factor (glucose) takes place in
the liver.
Digestion in the Mouth:
In the mouth, vigorous chewing of high-fibre foods slows eating and stimulates the flow
of saliva. The enzyme salivary amylase or ptyalin starts to work on cooked starch
hydrolysing it to shorter polysaccharides and to maltose. As food is in the mouth for only
a short time, very little digestion takes place there. Salivary amylase does not act on
raw starch. Cooked starch is more rapidly hydrolysed because the cell walls have been
ruptured and the enzymes have more ready access to the starch granules.
In the Stomach:
The swallowed bolus mixes with the stomach acids and protein-digesting enzymes.
Virtually, no chemical digestion of starch occurs in the stomach.
To a small extent, the stomach acids continue breaking down starch, but the juices
contain no carbohydrate digesting enzymes. Fibres linger in the stomach and delay
gastric emptying, thereby providing a feeling of fullness and satiety.

In the Small Intestine: Most work of carbohydrate digestion takes place in the alkaline
medium of the small intestines. A major carbohydrate-digesting enzyme, pancreatic
amylase, enters the intestine via the pancreatic duct and continues breaking down the
polysaccharides to shorter glucose chains and disaccharides. Pancreatic amylase
hydrolyses both raw and cooked starch to dextrins and, in turn, to maltose. The final
step takes place on the outer membranes of the intestinal cells where the intestinal
disaccharidases break down the disaccharides to monosaccharides, the end products
of CHO digestion.
Table 1: The specific enzymes that dismantle specific disaccharides:
Disaccharide Enzyme End product
Starch Amylase Glucose
Sucrose Sucrase Glucose + Fructose
Maltose Maltase Glucose + Glucose
Lactose Lactase Glucose + Galactose