OS 214: Digestion 1

Nutrition in Health and Disease

June 11, 2013
Gabriel V. Jasul, Jr., MD, FPCP, FPSEM and Edilberto B. Garcia Jr.,
MD MSPH

TOPIC OUTLINE

I. Introduction
A. Dietary Reference Intake Model
B. Healthy Eating Index
C. Dietary Recommendations
D. What’s Making Us Sick?
E. Common Algorithm of Managing Chronic Illness
F. Categories of “Toxicants”
G. Determination of Nutritional Status
Figure 3. A comparison of Healthy Eating Index scores between 1989-
II. National Nutrition Survey
1990 and 1999-2000 shows that healthy eating behaviors of adults have
A. Nutrition Survey Components
not changed much.
i. Anthropometric Survey Component
ii. Biochemical Survey Component
iii. Clinical Survey Component C. DIETARY RECOMMENDATIONS
iv. Dietary Survey Component
III. Nutritional Assessment
A. Purposes
B. Continuum of Nutritional Status
C. Nutritional Assessment of Individuals
D. Nutritional Assessment of Populations
E. Nutritional Assessment Methods
i. Anthropometric Measurements
ii. Biochemical Tests
iii. Clinical Observation
iv. Dietary Intake
F. Outcomes of Nutritional Assessment

Legends:
From the PowerPoint presentation
From the lecturer
From other sources (reference book, dictionary, news article) I. INTRODUCTION
A. DIETARY REFERENCE INTAKE MODEL
Figure 4. US Department of Agriculture Dietary Icons through the years.
Michelle Obama unveiled in 2011 the My Plate Method to better
visualize America’s dietary needs.

D. WHAT’S MAKING US SICK?

Figure 1. The Dietary Reference Intake model encompasses 4 nutrient-

based values: the estimated average requirement (EAR), the
recommended dietary allowance (RDA; prevents presence of Figure 5. Sum total of etiological determinants of illness
deficiency), the adequate intake (AI), and the upper level (UL;
possibility of too much intake). Increased risks are associated with both
inadequate intake and excessive intake.

B. HEALTHY EATING INDEX

Figures 6 and 7. Contemporary view of determinants of illness.

Deficiencies and Toxins/Toxicants have a different yet significant
contribution to the etiology of an illness.

E. COMMON ALGORITHM OF MANAGING CHRONIC ILLNESS

Assess the patient  Assign “diagnosis”  Therapeutic intervention

usually with medication or
Patient lives with chronic illness  surgery

Figure 2. The Healthy Eating Index is a measure of diet quality that F. CATERGORIES OF “TOXICANTS”
assesses conformance to federal dietary guidance (USDA CNPP, 2013).

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 Nutrition in Health and Disease OS 214

Table 1.  Collection of blood for hemoglobin determination

TOXICANT EXAMPLE  Collection of urine for urinary iodine excretion (UIE)
1. Chemical Heavy metals, mycotoxins
Nutritional Anemia
2. Biological Viral agents, fungal exposures
3. Physical Radiation, trauma  The 2008 NNS showed a decreasing trend in anemia
4. Metabolic Hyperinsulinemia, elevated uric acid prevalence among Filipinos. However, in certain packets of
the population, like infants 6 months to less than 1 year old, 1
5. Psychological Inordinate chronic stress, abuse
year old children, and pregnant women, nutritional anemia is
6. Hypersensitivity Intolerances such as peanut allergy
still a major health problem.

G. DETERMINATION OF NUTRITIONAL STATUS Iodine Deficiency Disorder

 The iodine status of children, 6-12 years/13-19 years, and
adults, 20-59 years and 60 years and over, are optimal as
indicated by median UIEs. The iodine status of pregnant and
lactating women is of public health concern.
 The proportion of children, pregnant and lactating women
with high UIE levels corresponding to “excessive” iodine
intake has increased.
 The proportion of households using iodized salt has
Figure 8. This figure shows that nutritional status is not the same as increased.
food intake, since the former is a process with several components.
iii. CLINICAL SURVEY COMPONENT
II. NATIONAL NUTRITIONAL SURVEY  Blood collection for lipid profile and fasting blood sugar
determination
Legal Basis:
 Measurement of blood pressure
EO 128 Section 22. The Food and Nutrition Research Institute (FNRI) is
mandated to: Hypertension
 Undertake research that defines the citizenry’s nutritional  The prevalence of hypertension among adults based on a
status, with reference particularly to the malnutrition problem, single visit was 25.3%; prevalence peaked at age 40-49.
its causes and effects, and identify alternative solutions to
them Diabetes Mellitus
 Develop and recommend policy options, strategies, programs
 The prevalence of high FBS (>125 mg/dL) among adults was
and projects; and
4.8%; peaked at age 50-59 with a prevalence of 9.0%.
 Disseminate research findings and recommendations
Dyslipidemia
EO 352. Designation of statistical activities that will generate critical date
for decision-making of the government and the private sector  Total cholesterol, LDL-c and triglyceride levels increased with
age, particularly rose between ages 40-60. The prevalence of
FNRI must conduct the NNS every 5 years and disseminate the results low HDL-c had remained relatively high from 2003 to 2008.
1 year after the reference year  Dyslipidemia based on total, HDL-cholesterol and triglyceride
levels had significantly increased from 2003 to 2008.
Millennium Development Goals
Target: 1c (hunger) and 4a (children mortality rate) iv. DIETARY SURVEY COMPONENT
 Interview on infant feeding practices through face-to-face
A. NUTRITION SURVEY COMPONENTS interview
A - Anthropometry  Exclusive breastfeeding of 0-5 month old children was only
B - Biochemical 35.9%. This implies that only more than 1/3 of the children
C - Clinical met the WHO recommendation of exclusive breastfeeding for
D - Dietary the first 6 months.
E - Economics  Of the total sample children, the proportion of ever breastfed
F - Food Insecurity children was 89.6%. Out of this ever breastfed, 82.8% were
G - Government Program Participation exclusively breastfed and 89.4% were given colostrum.
 The mean duration of exclusive breastfeeding was 2.3
i. ANTHROPOMETRIC SURVEY COMPONENT months. Compared with the 2003 which is 3.0 months, a
 Height and weight measurements significant decrease was noted.
 Comparing the mean duration of ever breastfeeding, the 2008
Among children, 0 to 10 years of age was slightly lower at 4.9 months versus 5.6 months in 2008.
 Undernutrition (based on weight-for-age and height-for-age) There was no significant difference between the 2 base year.
remains to be a public health problem, affecting nearly 3 out  Only 17.1% of the sample children were breastfed up to 12-
of 10 children. Between 2005 and 2008, the proportion of 23 months. This is far short of the recommended length of
undernourished children has significantly increased. breastfeeding by WHO which is up to 2 years of age.
 About 2 out of 10 children are overweight (based on weight-  Introduction of complementary foods to children was
for-age). However, this remains to be the same from 2005. between 4-6 months. Untimely or early stopping of
breastfeeding has been attributed by mothers to their work as
Among adolescents, 11 to 19 years of age well as inadequate flow of breastmilk.
 Underweight is nearly 2 out of 10 adolescents (based on
BMI-for-age), with males being more at-risk than females. III. NUTRITIONAL ASSESSMENT
Between 2005 and 2008, undernutrition among this age group  Nutritional Health
has significantly increased while overnutrition has o Obtaining all of the nutrients in amounts needed to support body
decreased. processes
o Can be measured in a number of ways
Among adults, 20 years of age and above  Process of measuring is called Nutritional Assessment
 About 1 in 10 adults are chronic energy deficient (CED),
while 3 out of 10 are overweight. A. Purposes
 The proportion of CED has decreased while overweight and
obese has increased between 2003 and 2008.  In clinic, help evaluate nutrition-related risks that may endanger a
person’s current or future health
Among pregnant and lactating women  In hospitalized patients, not only identify risks but also measures
 Undernutrition and overnutrition among lactating mothers the effectiveness of treatment
have decreased significantly from 2005.  In public health, nutrition assessment helps to identify people in
need of nutrition-related interventions and to monitor
effectiveness of intervention programs
ii. BIOCHEMICAL SURVEY COMPONENT

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B. THE CONTINUUM OF NUTRITIONAL STATUS  Instrument

UNDERNUTRITION o Calibrated scale – for a higher degree of precision, subtract
weight of clothing
 Poor health resulting from the depletion of nutrients due to
 Ask about the usual body weight and compare it with standard
inadequate nutrient intake over time
weight table
 Most often associated with  Check for any recent (significant) weight loss
o Poverty o 1-2% past week
o Alcoholism o 5% over past month
o 7-5% previous 3 months
o Some types of eating disorders o 10% in the past 6 months
- Unexplained weight loss on the elderly may be due to
OVERNUTRITION depressions or wasting disease (cancer)
 Long term consumption of an excess of nutrients
 Common type is due to the regular consumption of excess HEAD CIRCUMFERENCE
o Calories  Measured using flexible tape place snugly around the head
o Fat  Measurements compared to standard growth charts
 Done during the rapid growth from birth to age 3
o Saturated fats or cholesterol
SKIN FOLD
C. NUTRITIONAL ASSESSMENT OF INDIVIDUALS  Give good indication of body fatness
 Done by registered dietician or physician  Used to evaluate physical fitness of an athlete or predict the risk
 Detail depends on purpose of obesity-related disorders
 Maintenance of fat stores in a patient’s body may be a valuable
 Information can be used to plan individualized nutrition
indicator of dietary adequacy
counseling  Instrument: Special caliper
 Done repeatedly to assess the effectiveness of nutrition
counseling or a change in diet ii. BIOCHEMICAL TESTS
 Measure nutrient or its metabolite in one or more body fluids
D. NUTRITIONAL ASSESSMENT OF POPULATIONS o Blood (albumin)
 Not as comprehensive as an assessment of an individual o Urine (creatinine and urea)
 Example: National Nutritional Survey by FNRI o Feces
 Also called laboratory assessment
E. NUTRITIONAL ASSESSMENT METHODS  Complements anthropometric measurements which does not give
Table 2. The ABCD’s of Nutritional Assessment specific information about nutrients
ASSESSMENT METHOD RATIONALE  Include measurements of
Anthropometric measure Measure growth in children o A nutrient metabolite
Show changes in weight that can reflect o A storage or transport compound
diseases (e.g. cancer or thyroid problems) o An enzyme that depends on a vitamin or mineral
Monitor progress of fat loss o Or another indicator of the body functioning in relation to a
Biochemical tests Measure blood, urine, and feces for particular nutrient
nutrients or metabolites that indicate  Example case: concentration of albumin (a transport protein) in the
infection or disease blood as an indicator of the body’s protein status
Clinical observation Assess change in skin color and health, o If little protein is eaten, the body produces a smaller quantity of
hair texture, fingernail shape, etc.
albumin and other proteins
Dietary intake Evaluate diet for nutrients (e.g. fat,
 Better indicator of nutritional status than directly measuring blood
calcium, protein) or food intake (e.g.
levels of nutrients such as vitamin A or Ca2+.
number of fruits and vegetables intake)
 Level of nutrients excreted in urine/feces also provide valuable
i. ANTHROPOMETRIC MEASUREMENTS information
 Measurements of physical characteristics of the body (height,
weight, head circumference and skinfold measurements) iii. CLINICAL INFORMATION
 Useful in evaluating the growth of infants, children and adolescents,  Asses by evaluating the characteristics of well-being that can be
and in determining body composition seen in a physical exam
 Non-specific
HEIGHT o Can provide clues to nutrient deficiency that can be confirmed
 Must be accurately measured or ruled out by biochemical testing
 Recumbent length is measured for infants until 2 years of age  Clinician observes the hair, nails, skin, eyes, lips, mouth, bones,
 Careful measurement at each check-up gives a clear indication of a muscles, and joints
child’s growth rate o Cracking at the corner of the mouth suggests riboflavin,
 Standard growth charts to compare growth to others of the SAME vitamin B6 (pyridoxine) or niacin deficiency
age and sex o Petechiae (small pinpoint hemorrhages on the skin) is indicative
 Aging adults lose height due to bone loss and curvature, therefore of vitamin C deficiency
measuring height (and not just asking) is important  Needs to be followed by other assessments

 Instrument iv. DIETARY INTAKE

o Tape measure fixed to a wall
o Sliding right angle headboard for reading the measurement
 How to do it:
o Stand as straight as possible, without shoes or cap
o Heels together and looking straight ahead
o Heels, buttocks, shoulders, and head should be touching the wall
 Alternative methods for non-ambulatory patients
o Total arm length (tape measure must pass through clavicle)
o Arm span
WEIGHT
 A critical measure in nutrition assessment
 Used to assess children’s growth, predict energy expenditure and
protein needs, and determine body mass index
 May confirm the lack or excess of a dietary component suggested
by other methods of evaluation
 Quality of information obtained about people’s diet often relies on
people’s memories, as well as their honesty in sharing those
recollections
 There are a number of ways to collect dietary intake data and each
has strengths and weaknesses
DIET HISTORY
 Record of food intake and eating behaviors that include recent and
long term habits of food consumption
 Done by a skilled interviewer (since probing questions must be
asked)
 The most comprehensive form of dietary intake data collection

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FOOD RECORDS
 Detailed day-to-day eating habits
 Includes ALL foods and beverages consumed for a defined period
(usually three to seven days)
 Less prone to inaccuracy from lapses in memory
o Recorded concurrent with intake
o But if person fails to record all items, it will still be inaccurate

Weighed Food Records

 Obtained by weighing foods before eating and weighing left-
overs to determine exact amount consumed
 Time-consuming to complete

Food Frequency Questionnaire (FFQ)

 Asks how often subject consumes specific foods or groups of food
rather NOT what specific foods the subject consumes daily
 Also called food frequency checklist
 e.g.: “How often do you drink a cup of milk?
o Response options must be daily, weekly, monthly
 Used to estimate the person’s average daily intake
 Does NOT require trained interviewer
 Can be relatively quick to complete
 Disadvantage: difficult to translate a person’s response to specifics
o e.g. If patient answers daily, you would not know how many
times per day.

24-hour Diet Recall

 Interviewer ask recent 24-hour period (midnight to midnight) to
determine what foods and beverages the client consumed
 To get a complete and accurate picture of the client’s diet, probing
questions must be asked
o Leading questions must not be asked, e.g. “Did you put butter
and jelly on your toast?”, but instead ask, “Did you put anything
on your toast?”
 Method of data collection used on comprehensive population
surveys (e.g. NNS by FNRI)
 Single 24-hour recall is NOT very useful for describing an
individual’s diet’s overall nutrient content
o e.g. The individual ate at a buffet the day before

METHODS OF EVALUATING DIETARY INTAKE DATA

 After data collection, evaluate data using nutrient analysis
software
 Compare person’s intake to dietary standards such as RDA and AI
values
 Comparison to MyPyramid and Dietary Guidelines for Filipinos
o Gives idea if subject’s diet is high or low in saturated fats, or if
vegetable and fruit intake is enough

F. OUTCOMES OF NUTRITION ASSESSMENT

 Assessment may lead to:
o Recommendation for a diet change
o Addition of vitamin or mineral supplement to treat a deficiency
o Identification of abnormal growth due to inadequate infant
feeding
o Affirmation that dietary intake is adequate for current nutritional
needs
 Data are compared to established standards to
o diagnose nutritional deficiencies
o identify dietary inadequacies
o evaluate progress as a result of dietary changes

END OF TRANSCRIPTION

Kevin: Happy First Week!

Gelo: Hi 2017! Goodluck sa ating bagong pakikipagsapalaran! Tiwala

lang! Enjoy2x din tayo pag may time

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