Public Health Nutrition

1
Public Health Nutrition (Community Nutrition)
Instructor MC Huang
2
Nutrition and Diseases
??? ???
Biochemical Damage
? ? ???
Clinical Symptons

• Chronic Diseases
• Cancer
• CVD
• DM

Overnutrition undernutrition
Overnutrition
3
Public Health (Community) Nutrition

• Past problems undernutrition - goiter
  - beriberi, pellegra, scurvy
• Present problems overnutrition -
  malignant tumor - cardiovascular diseases
  - diabetes mellitus

4
??????Nutrition Health Survey in Taiwan
5
??????
??????????????????????????,1980????????????
6
??????

• ????????? (1980-81)
• ????????? (1986-88)
• 1993-1996 ????????? ????????
• 1997-2002 ????????? ????????

7
??????????

• ????
• ????
• ?????
• ????
• ???
• ????????
• ??
• ???????
• ??
• ????,???,??

8
????????? (1980-81)

• ????????????? (???????????)
• ??????????
• ????????
• ??12?? 539? 3163?

9
????????? (1986-88)

• ????????????? (???????????)
• ?? ????????
• ?? ??????
• ?? 12?? 552? 20176?

10
????????? (1993-96)???????????????

• ???????? ????
  24??????? ??????
  ??/??/????
• ?? ????????????
• ?? ??????/????
• ?? 21?? 63?? 10080?(????)

11
???????????????????

• ?????365????????
• ?? ?? ?? ??? ??? ???????????
• ?????????????? ??????
• ????? ???????
• ???????????????
• ??????????
• ????????????8-16???
• ?10080 ???? (??9962)

12
???????????????????

• ??
• ??
• ?????????????
• ???
• ??,???
• ????

13
???????????????????

• ???? ?120
• BMI ? 26.4
• ??????? ??20mm ??28mm
• ??? ??25 ??30
• ???? ??0.9 ??0.85

14
???????????????????????

• 24?????? - ???????????? - ? RDNA ??
• ?????? - ????????
• ?????????????? - ????????????????

15
????-????

• ?????????????
• SAS ????

16
?????????????????????

• ?? - ??????????????? - ???,???,???,???
• ???? - ?????,?????,???? ???,??,?? - ????

17
????????????

• ???????????? ?????????????
• ????????????? ????????, ??? ??????

18
????????? (1997-2002)???????????????

• ????????
• ???? ????
  ????
• ?? ??(??)??????????
• ?? ??????/????
• ?? 39?? 78?? 2028???

19
????????? (1997-2002)???????????????

• ????? - ????????
• ???? - ????????? - ?????????
• ???? - ???? - ????

20
???????????????????

• ?????????????????
• ?? ?? ?? ?? ??????
• ??????? ??????? ??????
• ????? ???????
• ??????26???
• ? 2028?

21
Community Nutrition in Actions

• Nutrition assessment in community - ABCD
• Nutritional program planning
• Nutrition education
• Marketing nutrition for health promotion
  and disease prevention
• Nutritional program management

22
Epidemiological Findings
Nutritional Assessment
Nutritional Plan- define the problems- define
goals objective- develop a program plan-
evaluate the program
Nutritional education
23
What knowledge doesa community nutritionist
need ??
24
Nutritional Assessment

• Definition The interpretation of information
  obtained from Anthropometric, Biochemical
  Clinical and Dietary studies.
• The information used to determine - health
  status of individuals or population -
  influenced by their intake and utilization of
  nutrients.

25
Anthropometric Measurement
Definition Measurements of the variations of the
physical dimensions and gross composition of the
human body at different age levels and degree of
nutrition
26
Anthropometric Measurement Growth measurement

• Head Circumference
• Weight - adult children
• Height - adult children

27
Ideal Body WeightAdult

• M 62 Ht (cm)-170) X 0.6
• F 58 Ht (cm)-158) X 0.5
• M Ht (cm)-80 X 0.7
• F Ht (cm)-70 X 0.6
• 22 X Ht (m2)

28
Indices for of wt change (adult)

• Usual Body Weight Ideal Body Weight X 100
  
• Ideal Body Weight
• Obese 20
• Overweight 10-15
• Normal 10 , normal
• Underweight - 10-15
• Marasmus - 20

29
Indices for BMI - adult

• Normal 20-24.9
• Obesity I 25-29.9
• Obesity II 30-40
• Obesity III gt 40

30
Indices for BMI 6-18 ?

• Usual BMI 22 X 100
• 22
• ?????????? - ?? 25-75 percentile - ?? 75-95
  percentile - ?? gt 95 - ?? 5-25
  percentile - ?? lt 5

31
Indices of growth for children 0-6 ????????

• Normal 25-75 percentile
• Normal ? 10-25/75-90 percentile
• Medical evaluation lt10 or gt90 percentile
• Priority for medical evaluation/follow up- lt5 or
  gt 95 percentile

• Use of Growth Charts
• Public health office
• Community Health
• Nutrition surveys
• Physicians office

32

Body Height - Direct Measurement

• ?? - gt 3 yr old
• ?? (recumbent Length) - 0-6 yr old
• ???? 0-6, 6-15, 8-19 yr ???????

33
Body Height - Indirect Measurement

• Arm Span
• Knee Height

Male 85.10 1.73X knee height 0.11 X
age Female 91.45 1.53X knee height 0.16 X
age
34
Body Composition Assessment

• Body fat content dependent on sex,
  height, weight
• Fat free mass mixture of water,
  protein, minerals

35
Body Fat kg fat or body wt

• Triceps skinfold (TSF) mid point of the
  back of the upper left arm
• Biceps skinfold (BSF) thickness of a
  vertical fold on the front of the upper
  left arm
• Subscapular skinfold (SSF) below and
  laterally to the angle of the left
  shoulder blade
• Waist/Hip ratio (W/H) M gt 0.9 Fgt0.8
  -gt
  increased CVD risk
  -gt ?????

36
Skinfold Meaurement

• Measurement tool capiler
• suitable for all ages measurement
• Indices body fat or energy storage status
• assessment reference (????)

• Assessment reference
• Normal 25-75 percentile
• Normal? 10-25 percentile, 75-90 percentile
• Excessive body fat gt 90 percentile
• Body fat/protein exhaustion lt10 percentile

37
Fat free mass

• Mid-upper-arm Circumference (MAC)
• Mid-upper-arm Muscle Circumference (MAMC)
  derived from MAC TSF MAMC MAC-3.14X
  TSF

38
Arm Circumferance fat free mass assessment

• Indices body energy/protein storage status
• MAC, MAMC usual indicator
• muscle area preferable indicator than
  MAC/MAMC
• assessment reference (????)

• Assessment reference (MAC/MAMC)
• Normal 60-90 percentile
• mild nutrition depletion 25-60 percentile
• moderate nutrition depletion 5-25 percentile
• severe nutrition depletion lt5 percentile

39
Fat mass fat area measurement

• Arm area (mm2) A (3.14/4) X
  (MAC/3.14)2
• Fat area (mm2) F A MAMA (mid-arm
  muscle area)

40
Skinfold Meaurement

• Measurement tool capiler
• suitable for all ages measurement
• Indices body fat or energy storage status
• assessment reference (????)

• Assessment reference
• Normal 25-75 percentile
• Normal? 10-25 percentile, 75-90 percentile
• Excessive body fat gt 90 percentile
• Body fat/protein exhaustion lt10 percentile

41
Correlations between Anthropometric variables
Body fat
body fat body fat Total body fat Total body fat
Men women Men women Men Women Men Women
Weight 0.67 0.70 0.82 0.91
TSF 0.70 0.77 0.73 0.80
SSF 0.75 0.71 0.79 0.80
Am J Clin Nutr, Roche et al, 1981
42
Conclude anthropometric measurement

• Body fat content combination of
  skinfold measurement
• distribution of subcutaneous fat
  Skinfold W/H ratio
• Fat free mass MAC TSF provide
  good indication for muscle area
• No anthropometric indices are good
  indicators for short term nutritional
  support or deprivation

43

Biochemical Measurement

• Laboratory assessment is used to detect
  subclinical deficiency state.
• It provides objective means of assessing
  nutritional status, independent of emotional
  and other subjective factors.

44
Biochemical Measurement

• measurement of a nutrient in biological fluid
  or tissues -gt Blood
  plasma/serum
  erythrocyte
  leukocyte/lymphocyte -gt tissues bone
  marrow, adipose tissues, bone
  hair, fingernails, toenails
  
• Urinary excretion rate of a nutrient
• Functional Tests measuring abnormal metabolite
  or enzyme activities dependent upon a
  nutrient

45

Distribution of Protein
Types g/kg Distribution
Muscle 22 Somatic protein (exchangeable)
Skeleton 20 Somatic protein (exchangeable)
Viscera 18 Visceral protein (exchangeable)
Extracellular 17 Connective tissues, Structural proteins
Fat 6
46
Somatic Protein Status

• Urinary creatinine excretion/24 hr M
  20-26mg /kg/24hr F 14-22 mg/kg/24hr
  
• Creatinine Height Index (CHI) CHI
  24hr urinary creatinine X 100
  Ideal 24hr urinary creatinine for Ht
  Normal condition 90-100
  moderate depletion 60-90 severe
  depletion gt60

47
Visceral protein status

• Albumin 3.55.0 g/dl
• Prealbumin 15.7-29.6 mg/dl
• Globulin serum globulin 2.33.5 gm/dl A/G
  ratio- 1.21.9 mg/dl
• Transferrin 200400 mg/dl
• RBP 2.67.6 mg/dl
• Total serum pro 6-8.4

48
Overall Protein Status

• Short Method nitrogen balance
  (protein intake/6.25)-(urinary urea
  nitrogen4)
• Long Method nitrogen balance I-
  (U-Ue)(F-Fe)S I nitrogen
  intake in gram U total urinary
  nitrogen Ue endogenous urinary
  nitrogen F Nitrogen excreted in
  feces Fe endogenous fecal nitrogen
  loss S dermal nitrogen loss

49
CVD Risk based on Lipoprotein Levels in DM Adults

Risk LDL Chol HDL Chol TG High gt
130 lt35 gt 400 Borderline
100-129 35-45 200-399 Low
lt 100 gt45 lt200

Data is expressed as mg/dl
50
Vitamin Assessment
Nutrient Examined Item
Vitamin A Serum Beta-carotene, Serum Retinol
Vitamin D 25-hydroxy-D3, alkaline phosphatase
Vitamin E Serum/plasma vitamin E
Vitamin K Clotting factors II, VII, IX, X, prothrombin Time
51
Vitamin Assessment..
Nutrient Examined Item
Vitamin B1 Erythrocyte transketolase Urine vitamin B1
Vitamin B2 Glutathione reductase, Erythrocyte/urine vitamin B2
Niacin Urine methylnicotinamide
Vitamin B6 Tryptophan loading test Pyridoxal phosphateerythrocyte transaminase (GOT/GPT)
52
Vitamin Assessment
Nutrient Examined Item
Folic acid Erythrocyte/serum folate Homocysteine
Vitamin B12 Erythrocyte/serum vitamin B12 Urine methyl malonic acid
Vitamin C WBC/serum vitamin C
53
Mineral Assessment
Nutrient Examined Item
Calcium Serum Ca, 24hr urinary Ca excretion
Phosphorus Serum phosphorus
Iodine Protein bound iodine, urinary iodine excretion, I125 absorption
Iron Serum Fe, total iron binding capacity Transferrin saturation
Zinc Serum Zn, hair Zn
54
Organ Function Tests
Organs Examined Item
Kidney BUN Creatinine Uric acid
Liver GOT GPT ALP LDH Ammonia
Pancrease Serum amylase Serum Lipase


55
Clinical Evaluation

• Clinical assessment consists of a routine
  medical history and a physical examination to
  detect physical signs and symptons
  associated with malnutrition.
• They are most useful during advanced
  stages of nutritional depletion.

56
Dietary Evaluation

• 24 Hour Dietary Recall
• Food Frequency
• Dietary History
• Food Diary
• Weighed Food Record

57
24 hr Dietary Recall

• Methods Recall the subjects exact food intake
  during the previous 24 hr period
• approach face to face interview
  phone call interview
  take home and record
• Pros large-scale survey, high participation,
  cost less, time efficient
• Cons memory dependent, ignore seasoning,
  avoid bad food, poor
  conception on serving size

58
Improving Validity of 24 hr Dietary Recall

• Assist with food cards, food models
• Combined with food frequency and dietary
  history
• Use repeated 24hr dietary record

59
Food Frequency Questionaire

• Methods use list of specific food items to
  record frequency of intakes over a given
  period. Only obtain qualitative,
  descriptive information on food
  consumption pattern
• Approach face to face interview
  self-administered questionaire
• Pros rapid low respondent
  burden high response rate
• Cons low accuracy

60
Food Frequency Questionaire vs Epidemiology

• Very often used in epidemiological studies
• Categorize subjects into low, mid, high
  intakes for comparison with risk/protective
  effects on certain health issues

61
Dietary History

• Methods Interview method consist a 24 hr
  dietary recall, questionaire on usual food
  intake pattern and followed by a food
  frequency questionaire. Such data is useful
  in food pattern associated with inadequate food
  intake.
• Approach face to face interview
• Pros understanding long-term food intake
  pattern high response rate
• Cons Labor intensive time
  consuming data validity is
  interviewers dependent

62
Weighed Food Record

• Methods All food consumed over a period is
  weighed. Useful in measuring actual
  intakes of individuals.
• Approach weighing food items at home
• Pros accurate time
  efficient
• Cons participants willingness decrease over
  time education dependent
  may affect subjects food intake habits

63
Nutritional Assessment-Session end
64
??????- ??????????????

• ????? 3-6 ?
• ?? 1-2?
• ????? 4?
• ??? 3?
• ??? 2 ?

u        ??????
u        ??????
u        ??????
65
Food Guide Pyramid (USA)

• Food Guide pyramid - to meet the
  nutritional needs for carbohydrate, protein,
  fat, vitamins minerals
• Not concerning the killer diseases in USA
  - DM, CVD, cancer, alcoholism
• Killer diseases are associated with -
  over-consumption of calorie, fat, cholesterol
  salt - under-consumption of calcium,
  iron, folate - dietary fiber

u        ??????
u        ??????
u        ??????
66
Dietary Guidelines for Americans

• Concerns - in response to diseases patterns
  in USA
• Dietary Guidelines - eat a variety of
  food - balance the food you eat with
  exercise - choose a diet with plenty of
  grains, veg fruit - choose a diet low in
  fat, SAT, cholesterol - choose a diet
  moderate in sugar - choose a diet moderate
  in salt sodium - If you drink alcohol, do
  so in moderation

u        ??????
u        ??????
u        ??????
67
Thank you for your attention
u        ??????
u        ??????
u        ??????
68
??????- ??????????????

• ??????
• ????????
• ????????
• ????????
• ???????????
• ?????????
• ?????
• ?????

u        ??????
u        ??????
u        ??????