Chapter 1: CLINICAL AND THERAPEUTIC NUTRITION

Learning Objectives:
After reading this unit, the students will be able to:
1. define the terms dietetics, clinical nutrition, therapeutic diet and explain the
concept of diet planning in disease,
2. enumerate the scope of dietetics and the role of dietitian in health care,
3. explain the relationship between nutrition and infection,
4. discuss the adaptation of normal diet to therapeutic diets, and
5. describe the types of therapeutic modifications with respect to consistency,
frequency of meals, methods of cooking etc,.

Welcome to the study of clinical and therapeutic nutrition. Earlier you

were introduced to public health nutrition which you learnt focuses on
health promotion and disease prevention in the general population.
Clinical nutrition, on the other hand, as a study focuses on the
nutritional management of individuals or group of individuals with
established disease condition. Clinical nutrition deals with issues such
as altered nutritional requirements associated with the disease, disease
severity and malnutrition and many such issues about which we will
learn in this unit and other units in this course. Nutrition is an integral
part of the medical therapy as adequate nutrition support can go a long
way in improving quality of care and improving patient's medical
outcome. The importance of nutrition in the prevention of illness and
disease has been long recognized. Do you recall your grandma's
homemade remedies for common illnesses such as fevers, cough/cold,
stomach ache, and indigestion or heart burn? Yes, nutritional care in
terms of providing hot cups of soup or porridge ensured that you were
adequately and appropriately nourished which helped improve
medical outcome. There is certainly more to clinical nutrition than
this. So let us get to know about clinical and therapeutic nutrition.

DIETETICS AND ROLE OF DIETITIAN IN HEALTH CARE

As a student of nutrition it must be evident to you by now that the diet

and the food we eat have a direct and significant impact on our health.
Eating a healthy balanced diet improves the quality of our life,

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whereas a poor diet may lead to morbidity and disease. The branch of
medicine concerned with how food and nutrition affects human health
comprising the rules to be followed for preventing, relieving or curing
disease by diet is called Dietetics. Dietetics deals with feeding
individuals based on the principles of nutrition. In fact, dietetics is the
science and art of human nutritional care.

Clinical Dietetics is the application of dietetics in a hospital or health

care institutional setting. Clinical dietetics focuses on individual
nutrition support and symptom management. You may come across
the terms diet therapy, therapeutic diets while studying about clinical
dietetics. Let us get to understand these terminologies used in the
context of dietetics.

Diet therapy is a branch of dietetics concerned with the use of food

for therapeutic purpose. Diet therapy is a broad term used for the
practical application of nutrition as a preventive or corrective
treatment of a disease. It concerns with recovery from illness by
giving good diet and prevention of disease. It may involve the
modification of the existing dietary lifestyle to promote optimum
health. For example a dietitian or a nutrition counselor may prescribe
a diet therapy to an obese person to improve health. The therapy may
involve including foods that improve the health condition while
avoiding foods (such as fats, sugars etc.) that may make the condition
worse. Basically the therapy promotes a balanced selection of foods
vital for good health. The principles of diet therapy are to:
 maintain good nutritional status,
 correct deficiencies or disease, if any,
 provide rest to the body,
 help metabolize the nutrients, and
 make changes in body weight, when necessary.
Diet therapy may include prescribing specialized dietary regimes or
meal plans. These specialized diet regimens or meal plans are called
therapeutic diets. Therapeutic diet refers to a meal plan that controls
the intake of certain foods or nutrients. They are adaptation of the
normal, regular diet. Some common examples of therapeutic diets
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 include clear liquid diet, diabetic diet, renal diet, gluten free diet, low
fat diet, high fibre diet etc. Therapeutic diets are usually prescribed by
dietitians, nutritionists or physicians. We will learn about the types of
therapeutic diets later in this unit.

Depending on the nature of the problem, a health care team might

include physician/doctor, nurses, nutritionists, dietitians, counselors
etc. But dietitian/nutritionists are at the forefront of nutritional care. A
nutrition professional can advice, counsel, coordinates, educate,
guide, inform, suggest and support. Nutrition professional works with
individuals/patients to help them understand that good nutrition and
good health go hand-in-hand. The various tasks and the role of
dietitian in health care are enumerated next.

Role of Dietitian in Nutrition Care

Dietitian you know is an expert in dietetics, dealing with human nutritional care. A dietitian apply the
science and principals of human nutrition to help people understand the relationship between food and
health and make appropriate dietary choices to attain and maintain health and to prevent and treat
illness and disease.

Dietitians work in a wide variety of roles in, for example, a clinical, public health or community, food
service, administrative, freelance/consultancy, research or teaching capacity. However, you will find
that majority of dietitians are clinical dietitians working in hospitals, nursing homes and other health
care facilities or specialized institutes/units to provide nutritional care to patients with a variety of
health conditions, and provide dietary consultations to patients and their families.
The activities most likely to be undertaken by the clinical dietitians would include:
 Collecting, organizing and assessing data relating to health and nutritional status of
individuals, groups and communities,
 Review and analyze patients nutritional needs and goals to make appropriate dietary
recommendations,
 Develop and implement nutrition care plans and monitor, follow up and evaluate these plans
and take corrective measures wherever required,
 Calculate nutritional value of food/meals planned,
 Prescribe therapeutic diets and special nutrition support and feeding regimens,
 Oversee the preparation of special diets, special nutrition formulas for patients who are
critically or terminally and require special feeding through oral, enteral or parenteral routes,
 Plan and prepare basic menus and assist in supervising food service personnel in preparing 3
menus and serving of meals,
 Schedule work assignments in the dietary unit to facilitate the effective operation of the
kitchen and other food preparation or dining areas,
 Therapeutic Diets: A Review

Remember, a therapeutic diet is a qualitative/quantitative modified

version of a normal regular diet which has been tailored to suit the
changing nutritional needs of patient/individual and are used to
improve specific health/disease condition. It is a planned diet used to
supplement the medical or surgical treatment. Balanced diet is defined as one which
contains a variety of foods in such
quantities and proportions that the need
Here you may enquire what a normal regular diet is. for energy, proteins, vitamins, minerals,
fats and other nutrients is adequately met
Normal diet, here, refers to a basic, balanced diet which
for maintaining health and well being.
meets the need of an individual.

Refer to Figure 1.1 which illustrates routine hospital diets.

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 Figure 1.1: Routine hospital diets
Normal or general diet in a hospital setting is a balanced diet which
meets the nutritional needs of an individual/patient. It is given when
the individual's medical condition does not warrant any specific
modification. Most hospitals follow simple dietary recommendations
(given by ICMR for Indian population) while planning the general
diet. It is planned keeping the basic food groups in mind so that
optimum amount of all nutrients is provided. Further, since the patient
is hospitalized or on bed rest, reduction of 10% in energy intake
should be made. The diet provides approximately 1600 to 2200Kcal,
and contain around 180 to 300g carbohydrates, 60 to 80g of fat and 40
to 70 g of protein.

Figure 1.1 also illustrates the soft diet and the liquid diets which are
examples of therapeutic diet. In addition to these there may be other
modified diets which individuals may require as part of their
therapeutic needs. The reasons for modifying the diets may include:

 For essential or life saving treatment: For example in celiac

disease, providing gluten free diet,
 To replete patients who are malnourished because of disease
such as cancer and intestinal diseases by providing a greater
amount of a nutrient such as protein,
 To correct deficiencies and maintain or restore optimum
nutritional status,
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  To provide rest or relieve an affected organ such as in gastritis,
 To adjust to the body's ability to digest, absorb, metabolize or
excrete: For example a low fat diet provided in fat
malabsorption,
 To adjust to tolerance of food intake. For example in case of
patients with cancer of esophagus tube feeding is recommended
when patients cannot tolerate food by mouth,
 To exclude foods due to food allergies or food intolerance,
 To adjust to mechanical difficulties, for example for elderly
patients with denture problems, changing the texture/consistency
of food recommended due to problems with chewing and/or
swallowing,
 To increase or decrease body weight/body composition when
required, for example as in the case of obesity or underweight,
 As helpful treatment, alternative or complementary to drugs, as
in diabetes or in hypertension
The significance of modified or therapeutic diet is that it is useful in
managing the disease condition; it promotes resistance to disease
condition and is preventive or supplemental treatment. To help you
understand, consider this aspect. When an individual suffers from a
disease, the disease process may cause the patient to lose appetite and
therefore eat less or in some other circumstances feel more hungry
and eat more. Some individuals may have problems with digestion or
absorption of food or specific nutrient leading to changes in the type
of food which can be tolerated as also the frequency of feeding may
need to be altered. Dietary modification than becomes a part of the
therapeutic demand. There are many types of dietary modifications. A
checklist of some common modifications is presented in the next sub
section.
Types of Dietary Adaptations for Therapeutic Needs

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A diet may need to be altered and adjusted in many ways before it
meets the therapeutic needs of an individual patient. These
adaptations may include:
 Change in consistency of foods, such as liquid diet, soft diet,
low fibre diet, high fibre diet.
 Increase or decrease in energy value of the diet such as low
calorie diet for weight reduction, high calorie diet for burns.
 Increase or decrease in specific nutrients or type of food
consumed, such as sodium restricted diet, lactose restricted diet,
high fibre diet, high potassium diet.
 Elimination of spices and condiments, such as bland diets.
 Omission of specific foods such as allergy diets, gluten free diet.
 Adjustment in the ratio and balance of proteins, fats and
carbohydrate such as diabetic diet, renal diet and cholesterol-
lowering diets.
 Test diets: These are single meals or diets lasting one or few
days that are given to patients in connection with certain tests
e.g. the fat absorption test used to determine if steatorrhoea is
present.
 Change in frequency of meals, feeding intervals, re-arrangement
of the number and frequency of the meals such as diabetic diet,
diet for peptic ulcer disease.
Remember, normal nutrition is the foundation upon which the
therapeutic modifications are made. The various dietary adaptations
for therapeutic needs are briefly highlighted here.

A. Diets of Altered Consistency

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Therapeutic diets are modified for consistency, texture to fit the
nutritional needs. Some individuals may require a clear liquid diet,
while others a fully liquid diet or soft diet based on their medical
condition. Figure 1.2 illustrates the modified diets based on
consistency.

Figure 1.2: Modifications in consistency

a) Liquid Diet consists of foods that can be served in liquid or
strained form in room temperature. They are usually prescribed in
febrile states, postoperatively i.e. after surgery when the patient is
unable to tolerate solid foods. It is also used for individuals with acute
infections or digestive problems, to replace fluids lost by vomiting,
diarrhoea. The two major types of liquid diets include - Clear liquid
diet and full liquid/fluid diet.

i) Clear liquid diet provides foods and fluids that are clear and liquid
at room temperature. The purpose of the clear liquid diet is to provide
fluids and electrolytes to prevent dehydration. It provides some
amount of energy but very little amount of other nutrients. It is also
deficient in fibre. Hence it is nutritionally inadequate and should be
used only for short periods i.e. 1-2 days. An average clear liquid diet
contains 600 to 900Kcal, 120 to 200g carbohydrate, minimal fat 5 to
10g protein and small amount of sodium and potassium (electrolytes).
The clear liquid diet is usually useful in situations when the
gastrointestinal tract has to be kept functionally at rest. It is also
prescribed before and after certain types of surgery involving the
mouth or gastrointestinal tract. Also may be used in acute vomiting or
diarrhoea.
Examples of clear liquid diet: Water, strained fruit juices, coconut
water, lime juice (nimbu pani), whey water, barley/arrowroot water,
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rice kanji, clear dal soup, strained vegetable or meat soup, tea or
coffee without milk or cream, carbonated beverages, ice pops, plain
gelatin are some examples of clear liquid diet.

ii) Full liquid diet provides food and fluids that are liquid or semi
liquid at room temperature. It is used as a step between a clear liquid
diet and a regular diet. The purpose of the full liquid diet is to provide
an oral (by mouth) source of fluid for individuals who are incapable
of chewing, swallowing or digesting solid food. It provides more
calories than the clear liquid diet and gives adequate nourishment,
except that it is deficient in fibre. It is indicated for post operative
patients and for gastrointestinal illness. An average full liquid diet can
provide approximately 1000 to 1800 calories and 50 to 65g of protein
and adequate minerals and vitamins. The nutritive content of the full
liquid diet can be increased by using protein, vitamin and fibre
supplements.
Examples of full liquid diet: Foods allowed or included in a full liquid
diet include beverages, cream soups, vegetable soups, daal soups,
strained food juices, lassi/butter milk, yougurt, hot cocoa, coffee/tea
with milk, carbonated beverages, cereal porridges (refined cereals)
custard, sherbet, gelatin, puddings, ice cream, eggnog, margarine,
butter, cream (added to foods), poached, half boiled egg etc.

b) Soft diet as the name suggests provides soft whole food that is
lightly seasoned and are similar to the regular diet . The term 'soft'
refers to the fact that foods included in this type of diet are soft in
consistency, easy to chew and made of simple, easily digestible foods.
It does not contain harsh fibre or strong flavours. It is given during
acute infections, certain gastrointestinal disorders and at the post
operative stage to individuals who are in the early phase of recovery
following a surgery. The soft diet provides a transition between a
liquid and a normal diet i.e. during the period when a patient has to
give up a full liquid diet but is yet not able to tolerate a normal diet.
Soft diet can be nutritionally adequate (providing approximately
1800-2000 calories, 55-65g protein) provided the patient is able to
consume adequate amount of food.

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Examples of soft diet: A soft diet freely permits the use of cooked
vegetables, soft raw fruits without seeds, broths and all soups, washed
pulses in the form of soups and in combination of cereals and
vegetables (like khichri, dalia), breads and ready-to-eat cereals (most
preferable refined such as poha, upma, pasta, noodles etc.), milk and
milk beverages, yogurt, light desserts (including kheer, halwa,
custard, jelly, ice cream), Egg and tender and minced, ground, stewed
meat and meat products, fat like butter, cream, vegetable oil and salt
and sugar in moderation. Foods to be best avoided in the soft diet
include coarse cereals, spicy highly seasoned and fried foods, dry
fruits and nuts, rich desserts.
Among the soft diet is also the mechanical soft diet also known as the
dental diet which is a normal diet that is modified only in texture for
ease of mastication i.e. chewing. When an individual cannot chew or
use facial muscles for a variety of dental, medical or surgical
conditions mechanical soft diet is recommended. Elderly persons who
have dental problems are prescribed mechanical soft diets. The food
in mechanical soft diet is similar to the soft diet and may be full
liquid, chopped, pureed or regular food with soft consistency. Simple
salads, fruit salads and cottage cheese may be included. No food is
restricted unlike in the case of the customary soft diet. Just removing
the skin and seeds, cutting or chopping the food into small fine pieces
are processes usually employed.

c. Bland Diet: A bland diet is made of foods that are soft, not very
spicy and low in fiber. It consists of foods which are mechanically,
chemically and thermally non-irritating i.e. are least likely to irritate
the gastrointestinal tract. Individuals suffering from gastric or
duodenal ulcers, gastriris or ulcerative colitis are prescribed this diet.
Foods Included: Milk and milk products low in fat or fat free; Bread,
pasta made from refined cereals, rice; cooked fruits and vegetables
without peel and seeds; Eggs and lean tender meat such as fish,
poultry that are steamed, baked or grilled; Cream, butter; Puddings
and custards, clear soups.
Foods Avoided: Fried, fatty foods; Strong flavoured foods; Strong tea,
coffee, alcoholic beverages, condiments and spices; High fiber foods;
hot soups and beverages; whole grains rich in fiber; strong cheeses.

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B. Modification in Quantity
Depending on the clinical condition some individuals may require a
restriction diet such as sodium restricted diet (as in high blood
pressure), purine restricted diet (as in gout) or low residue diet
(prescribed and/or before abdominal surgery) designed to reduce the
frequency and volume of fecal output. Sometimes a complete
elimination diet may be recommended when there is food intolerances
or complete insensitivity to a particular food such as a gluten free diet
or a dairy free diet or nut free diet etc. Occasionally an increase in the
amount of a specific dietary constituent may be prescribed such as a
high potassium diet or a high fibre diet (as in constipation) or an iron-
rich diet (as in anaemia) when the clinical condition demands.

C. Modification in Nutrient (Proteins, Fat, Carbohydrate) Content

The nutrient content of the diet is modified to treat deficiencies,
change body weight or control diseases such as hypertension or
diabetes. You may have come across patients with high blood sugar
levels, being prescribed a diabetic diet which requires changes in the
quantity and type of carbohydrates included in each meal. Refined
carbohydrates (such as sugar, honey, refined flour, semolina etc.) are
best avoided and use of complex carbohydrates (whole wheat flour,
coarse cereals etc.) recommended. Patients with heart diseases require
a fat controlled low cholesterol diet while patients with renal (kidney)
failure and advanced liver diseases a low protein diet, patients with
HIV disease, cancer or malnourished a high protein, high calorie diet.
Others as in the case of overweight, obesity a weight reduction diet,
low in fat and calories.

D. Changes in Meal Frequency

Individuals suffering with gastro-esophageal reflux disease (GERD)
stand to benefit by consuming small but frequent meals. 5 to 6 small
meals instead of three regular meals are recommended.

E. Changes in Method of Cooking

Leaching is indicated for cooking vegetables for people with chronic
kidney diseases because the kidney's no longer maintain the ideal

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level of potassium necessary for optimum health. Leaching (soaking
in water) drains out excessive potassium and phosphorous from the
vegetables. In elderly people food may be modified by mechanical
processing such as mashing, blendrizing or chopping. For patients on
bland diet foods steamed, baked or grilled are recommended. A
review on the methods of cooking is presented for your understanding
at the end of the book.

F. Modification in the Method of Feeding

To provide adequate nutrition, normally oral feeding (by mouth) is
recommended. Sometimes oral feeding is not possible, under such
circumstances special feeding methods such as enteral feeding
(provision of liquid formula diet delivered via nasogastric feeding
tube) and parenteral feeding (fluids containing water, glucose, amino
acids, minerals, vitamins given through the peripheral and central
veins) is recommended.

Here we have just introduced to you some common dietary

modifications. A detail review on modified therapeutic diets in
different disease conditions will be presented later in the units.

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 Chapter 2: NUTRITION AND INFECTION

Learning Objectives:
After reading this unit, the students will be able to:
1. discuss the interaction between nutrition and infection,
2. describe the effect of infection on nutritional status,
3. discuss how malnutrition can lead to infection,

The role of nutrition in disease prevention and health

management is well established. Also you are aware that poor
nutrition can lead to ill health, disease and infections.
Infections are caused by microorganisms which in turn can
lead to malnutrition. Is there a link between these two
conditions? In this section we shall discuss the interaction of
infection and nutrition.

Infection and malnutrition have always been intricately

linked. Evidence suggests that common childhood infections
exert their influence in precipitating malnutrition. The
relationship between malnutrition, impaired immunity and
infection can be described as a vicious cycle. We will learn
about this vicious cycle in this unit.

THE CYCLE OF MALNUTRITION AND INFECTION

Malnutrition, as you already know, is an impairment of health

resulting from a deficiency or lack of food/nutrients or
imbalance of nutrients in the diet. Almost any nutrient

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deficiency, if sufficiently severe, will impair resistance to
infection. Figure 1 illustrates this concept.
Let us understand this interaction between malnutrition and
infection with the help of a case study. Raju, a 4 year old boy,
is suffering from infectious diarrhoea, caused by the invasion
of the body by harmful microorganisms. The infection caused
loose motion, fever, dehydration and impaired absorption. On
further investigation he was also found to be suffering from
protein energy malnutrition reflecting as loss of weight. Now,
when these two diseases exist in the same person (here Raju)
concurrently, the interaction between the two diseases usually
alters the nature, behaviour of the diseases. The overall
clinical status of the child worsens often resulting in increased
complications or increased duration of the disease and in some
cases results in death. In case of Raju, infection is a common
precipitating factor for malnutrition. Ironically, malnutrition is
also a major factor in the occurrence of infection and the two
interact, making each other worse. Figure 1 illustrates this
interaction.

Figure 1: Interaction between infection and malnutrition

An inadequate dietary intake, in case of Raju, led to weight

loss, lowered immunity, mucosal injury, invasion by
pathogens, and impaired growth and development as
highlighted in Figure 2. Raju's nutrition was further

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aggravated by diarrhea, malabsorption, loss of appetite,
diversion of nutrients for the immune response, and urinary
nitrogen loss, all of which lead to nutrient losses and further
damage to defense mechanisms making him more susceptible
to infections. This in turn led to further reduced dietary intake
causing a vicious cycle of malnutrition and infection as
highlighted in Figure 1.

Figure 2: The vicious cycle of malnutrition and infection

So when infection aggravates malnutrition or malnutrition

lowers resistance to infection, the relationship between the
two can be described as Synergism i.e. the simultaneous
presence of malnutrition and infection results in an interaction
that is more serious for the individual than would be expected
from the combined effect of the two working independently.

The synergistic effect of malnutrition and infection often leads

to a high rate of child deaths in poor households/communities
in India. What generally happens is that in a poor rural/slum
household a child is as such born with low birth weight (that
is less than 2.5kg) because of inadequate dietary intake of the
mother during pregnancy. Subsequently the child is solely
breast fed for long periods (2 or more years). Complementary
feeding (i.e. introduction of additional foods other than breast

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milk) is delayed beyond 6 months of age. This triggers growth
faltering that is the child's growth and development slows
down resulting in weight loss. In other terms malnutrition sets
in. Moreover, in view of the poor environment and lack of
hygiene so common in rural/slum areas, the children are
further exposed to infections like diarrhoea and respiratory
tract infections. There is reduction in food intake by the child
due to loss of appetite due to these infections. As a result there
is further slowing down of growth. The cumulative effect of
dietary deficit and infection produces retardation of physical
growth leading to stunting (short stature or low height/length
for age as compared to normal child) in children. It is
important to highlight here that the effects of stunting are long
lasting. Children who are stunted grow up to be adults with
reduced capacity to do physical work and are less
economically productive.

From your understanding of the concept above now can you

summarize the effect of malnutrition on infection and the
reciprocal relation i.e. the effect of infection on nutritional
status? Summarize the points in the space provided:

Now check your responses with the summarized list presented

next. The basis of the effect is also described for your
understanding

Effect of Malnutrition on Infection

With reference to Figure 1 and 2, it must be evident to you
that inadequate nutrient intake lowers immunity. Also it leads
to mucosal damage. Let us get to know more on this aspect.

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a) Lowered Immunity: Immunity, in simple terms can be
described as the state of being unsusceptible or being
protected against a particular disease or illness by the presence
of particular substance in the blood. These particular disease
fighting substances are called antibodies. A healthy well
nourished child/individual is at a lower risk of infection. They
can fight the infection better. Why? Because of the ability of
these well nourished individuals to produce these disease
fighting substances called antibodies. But in case of
malnourished individuals there is reduction in antibody
production and therefore the disease fighting capacity is
lowered making the individual more prone to infections.
Hence you would notice that children who are suffering from
specific nutrient deficiencies such as protein energy
deficiency or iron deficiency anaemia or vitamin A deficiency
are prone to infections

b) Effect on the integrity of skin and mucous membrane:

Dietary inadequacy diminishes resistance to infection by
reducing the integrity of various tissues. In a healthy well fed
individual the skin, musosal membrane and other tissues are
healthy and prevent the entry of infectious agents. They act as
a barrier and prevent the infection from entering the body. In
an individual suffering from malnutrition, the protective
mechanism is absent. The mucous membrane becomes readily
permeable and provides a favorable environment for the
growth of the infectious agent. Consequently the individual
will catch infection easily.

Next let us study about the effect of infection on the

nutritional status.

Infection and Nutritional Status

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Infection, no matter how mild, has adverse effects on
nutritional status. Nutritional status, as you may recall, refers
to the condition of health of an individual as influenced by the
utilization of the nutrients. So how does infection influence
the utilization of the nutrients which in turn influences
nutritional status? Let us understand. There can be multiple
ways but the first and foremost effect of infection is on loss of
appetite.

a) Loss of Appetite: Do you recall the last time you were sick
or down with some infection? What did you experience? Yes,
you may not have been eager to consume food or were not
able to tolerate food leading to loss of appetite. Further with
use of medicines such as antibiotics to treat the infection your
appetite may have been further affected leading to reduced
food intake. Now if this condition would have been prolonged
it would have led to consistent decrease in food intake leading
to nutrient deficiency.

b) Unfavorable cultural practices: One of the common

practices in our country is to restrict or withdraw food from
individuals when suffering from infection, particularly
diarrhoea or respiratory infections. It is believed that solid
foods, milk etc. be best avoided instead bland, starchy gruels
low in nutritive value be provided to rest the digestive system.
Such a practice is deleterious; particularly when the individual
due to infection is already having low food intake and further
reduction in the quality of diet contributes to nutrient
deficiencies and thus leading to poor nutritional status.

c) Decreased intestinal absorption: The main function of

intestine is to digest, absorb and propel food along its length.
During infection all these functions are affected. Infections

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cause's changes to the epithelial membrane leading to
malabsorption. Any decrease in the absorption of nutrients can
lead to deficiency. For example in children suffering from
infectious diarrhoea, protein absorption from intestine may
reduce as much as 40%. Other evidence suggests that in
children with acute diarrhoea and respiratory infections only
30 -70 per cent of ingested vitamin A is absorbed. Poor
absorption thus leads to nutrient deficiency disorders
influencing nutritional status.

d) Worm/parasite infection: Also there are documented

reports implicating intestinal worm/parasitic infections with
poor nutritional status. Hookworm, round worm infection,
amoebiasis, giardiasis are among the most common intestinal
parasitic infections worldwide. These infections are associated
with decreased child growth, loss of weight, chronic blood
loss, iron deficiency anaemia, diarrhoea and stunted growth.

e) Protein loss: In some infections and fevers, few nutrients,

particularly proteins are excreted and lost from the body thus
causing poor nutritional status. For example diseases
associated with diarrhoea, dysentery produce an average loss
of 0.9g protein per kg body weight per day. Higher losses are
observed with typhoid fever and other acute infections,
reaching 1.2g protein/kg body weight/day. Such losses
therefore contribute to increased requirement of protein during
infection and fevers.

From the discussion above it must be evident to you that the

overall effect of the infections on the nutritional status is
substantial. In the context of developing country like India,
where large number of children, are already on a deficient diet
and malnourished, the coexistence of infection in the same

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child is producing the effect that is beyond the summed effect
expected from the two conditions acting alone.