introduction to nutritionf (1).pdf

Dr. Abdalhafeez Osman Mahmoud MBBS: Gezira University MPH: Kuala Lumpur MD: SMSB Associate Prof. CM Director of; Quality in Gezira and PHC in Umdurman – Ombadda. Universities (ME): Gezira, Shendi, Hail, Wadinneel, Merrowie, Kassala and now; UMST  Community Medicine 3 Phase 1...

Dr. Abdalhafeez Osman Mahmoud MBBS: Gezira University MPH: Kuala Lumpur MD: SMSB Associate Prof. CM Director of; Quality in Gezira and PHC in Umdurman – Ombadda. Universities (ME): Gezira, Shendi, Hail, Wadinneel, Merrowie, Kassala and now; UMST  Community Medicine 3 Phase 1 Course name: Community Medicine 3; phase 1 Course code: COMED3-1 Credit hours: 2 hrs. Academic year: third year Semester: 5 th. Pre-requisite course: Scientific English…… KMB-N UMST 2022 2  General objective: The general objective of this course is to cover the areas of foods and nutrition, health economies, health insurance and health promotion from a scientific approach, to prepare students for many nutritional and health-related problems. KMB-N UMST 2022 3  Specific Objectives: By the end of the course the student will be able to: Describe the nutritional national health programs. Observe and interpret the dynamic of community behaviors concerning nutrition. Enunciate the principles and components of primary health care and the national health policies to achieve the nutritional goals. Describe the importance of nutrition for human health. To understand the principles of nutrition, health economies, health insurance, health administration and hospital management, health education in relation to community and uses of computers in medical practice. Diagnose and manage common nutritional problems at the individual and community level. KMB-N UMST 2022 4  Theory lectures Nutrition and Health. Health Economics Health Insurance Health Promotion Hospital Management Computers in Medicine KMB-N UMST 2022 5 Nutrition and Health. Introduction to Nutrition Protein Energy Malnutrition-PEM Integrated management of Child Illness-IMCI  Definition Nutrition defined as the science of food and its relationship to health. It is concerned primarily with the part played by nutrients in body growth, development and maintenance KMB-N UMST 2022 9  Simply put the word nutrition is used to refer to the processes of the intake, digestion and assimilation of nutrients and the application of this knowledge to maintain health and combat disease. KMB-N UMST 2022 10 The word Nutrient or "food factor" is used for specific dietary constituents such as proteins, vitamins and minerals. Dietetics is the practical application of the principles of nutrition; it includes the planning of meals for the well and the sick. Good nutrition means "maintaining a nutritional status that enables us to grow well and enjoy good health" KMB-N UMST 2022 11  Significance and Importance ❖Epidemiological data shows strong association between under nutrition and morbidity / mortality. ❖Chronic degenerative disorders such as coronary artery disease, hypertension, type 2 diabetes, certain cancers, etc are related to diet and nutritional status KMB-N UMST 2022 12 ❖Obesity is associated with higher risk of developing cancer breast, colon, endometrium, gallbladder, esophagus, pancreas, etc. ❖Consumption of foods rich in dietary fiber and antioxidants is associated with reduced risk of certain cancers KMB-N UMST 2022 13 ▪ Under nutrition during foetal and early childhood is known to be associated with chronic degenerative disorders in later life Good nutrition is a fundamental requirement for positive health, functional efficiency and productivity. KMB-N UMST 2022 14  Nutritional status is internationally recognized as an indicator of national development. Nutrition is both an input into and an output of, the developmental process. KMB-N UMST 2022 15  NUTRIENTS ❖ Nutrients are organic and inorganic complexes contained in food. ❖ There are about 50 different nutrients which are normally supplied through the foods we eat. ❑ Each nutrient has specific functions in the body. ❑Most natural foods contain more than one nutrient. ❑These may be divided into: KMB-N UMST 2022 16  (i) Macronutrients : These are proteins, fats and carbohydrates which are often called "proximate principles“ because they form the main bulk of food. KMB-N UMST 2022 17 (ii) Micronutrients : These are vitamins and minerals. They are called micronutrients because they are required in small amounts which may vary from a fraction of a milligram to several grams KMB-N UMST 2022 18  CLASSIFICATION OF FOODS There are many ways of classifying foods 1. Classification by origin 1) Foods of animal origin 2) Foods of vegetable origin 2. Classification by chemical composition 1) Proteins 2) Fats 3) Carbohydrates 4) Vitamins 5) Minerals. KMB-N UMST 2022 19  3. Classification by predominant function 1) Body-building foods, e.g., milk, meat, poultry, fish, eggs, pulses, groundnuts, etc. 2) Energy-giving foods, e.g., cereals, sugars, roots and tubers, fats and oils. 3) Protective foods, e.g., vegetables, fruits, milk KMB-N UMST 2022 20  4. Classification by nutritive value 1) Cereals and millets 2) Pulses (legumes) 3) Vegetables 4) Nuts and oilseeds 5) Fruits 6) Animal foods 7) Fats and oils 8) Sugar and jaggery 9) Condiments and spices 10) Miscellaneous foods. KMB-N UMST 2022 21  Food categories 1- Milk & milk products 2- meats & legumes 3- cereals and starchy roots 4- vegetables & fruits Items in above groups when consumed by man is broken into 2parts: A. nourishing elements B. non-nourishing elements Group A include 3 groups: -body building elements e.g. proteins, Fe, Ca, Iodine -Energy producing elements e.g. CHO (1gm=4k.cal), fat (1gm=9k.cal) and proteins(1gm=4k.cal) -Protective &catalysts e.g. vitamins & metals Groups B include items that may be useful e.g. fibers or harmful such as toxins infectious agents  Dietary requirement & Recommended Intake Daily nutrient requirement= minimum amounts of nutrients needed to maintain normal health &growth (age, sex, body wt., activities, physiological states) Recommended intakes= nutrients requirements +safety margin to allow for individual variations (mean +or- 2SDs) Note: 1-the amount of food from each item is calculated on calorie yield of the item plus contents of other nutrients 2-nutrition planning= preparation of balanced meal that give the best requirement of different nutrient or recommended intake 3- the daily requirement of food must be derived from food items that collectively yield the daily requirements of calorie from CHO (65%) Fat (20%) PROTEIN (15%). - These food items should also collectively give the daily requirement of different important nutrients - To achieve this goal; food consumption table should be used KMB-N UMST 2022 26  Factors altering the daily requirement of nutrients Biochemical individuality Genetic differences Gender Pregnancy Lactation Growth Infections and Other diseases Surgery Drug-Nutrient interaction Smoking Alcohol Caffeine Environmental pollutants Activity or Exercise level Diet factors e.g. intake of : Carbohydrates; Fat; Fibre; Proteins KMB-N UMST 2022 27  Nutrition of at risk: - Pregnant -Lactating -Infants & under- 5 Note: -Daily Calories requirement of Pregnant increase by 350k and must be derived from high proteins , Fe and folate - Daily Calories requirement of lactating increase by 550k - Exclusive breast feeding in first 4month is very important for normal growth then weaning food must be introduced.  Nutritional Assessment: nutritional indicators: -food availability -food storage -food distribution -food quality -food quantity -food hygiene -Food tradition & taboos -Nutritional status indicators  Nutritional status indicators: They are used in assessment of the nutritional status of an individuals or of the community by studies on samples 1-Anthropometric indicators: Birth wt., wt./age (for under5) wt/Ht (for under5) , Ht/age (for under5) , MUAC, BMI 2- Biochemical indicators: Hb level, Albumin/Globulin ratio, serum level of micronutrients i.e. vitamins & minerals 3-Cinical indicators: e.g. for PEM: edema skin changes etc for anemia: pallor dyspnea etc  Nutritional status indicators: (cont.) 4-Biophysical indicators: Asses bone age by x-ray 5-Statistical (Epidemiological) indicators: Infants mortality rates Under5 morbidity & mortality rates KMB-N UMST 2022 32  Malnutrition Definition: Abnormal nutritional status of an individual or a community Classification: Based on 1-state of nutrition (deficiency or excess) 2-type of nutrient (macro or micronutrient)  Accordingly there are the following 4 groups: A- Macro-nutrient excess e.g. obesity B- Macro-nutrient deficiency e.g. marasmus C-Micro-nutrient excess e.g. hypervitaminosis A D-Micro-nutrient deficiency e.g. vitamin A deficiency Protein Energy Malnutrition PEM KMB-N UMST 2022 35  Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition addresses 3 broad groups of conditions: undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age) and underweight (low weight-for- age); micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess; and overweight, obesity and diet-related noncommunicable diseases (such as heart disease, stroke, diabetes and some cancers). KMB-N UMST 2022 36  Malnutrition, in all its forms, includes undernutrition (wasting, stunting, underweight), inadequate vitamins or minerals, overweight, obesity, and resulting diet- related noncommunicable diseases. In 2022, 2.5 billion adults were overweight, including 890 million who were living with obesity, while 390 million were underweight. Globally in 2022, 149 million children under 5 were estimated to be stunted (too short for age), 45 million were estimated to be wasted (too thin for height), and 37 million were overweight or living with obesity. KMB-N UMST 2022 37  Nearly half of deaths among children under 5 years of age are linked to undernutrition. These mostly occur in low- and middle-income countries. The developmental, economic, social and medical impacts of the global burden of malnutrition are serious and lasting, for individuals and their families, for communities and for countries. The developmental, economic, social and medical impacts of the global burden of malnutrition are serious and lasting, for individuals and their families, for communities and for countries. KMB-N UMST 2022 38 KMB-N UMST 2022 39  Protein Energy Malnutrition -PEM Type of Malnutrition (Mn) resulting from deficiency of protein and calories in food over a long period of time. Very common among young children and those below 10 years are sally affected and infants are hit hardest. Most serious form are Kwashiorkor (kw) and Marasmus (mr) Marasmus is more frequent. They are extreme forms of single condition- 80% goes not recognized (tip of iceberg) KMB-N UMST 2022 40  Importance ❖MN is the most imp. cause of mortality for children ❖49% of 10.4 millions death occur in children younger than 5 yr in developing countries are associated with MN (5 millions die of hunger) ❖95% of MN occur in tropic and subtropics, more than 70% of children with PEM live in Asia, and 26% in Africa.4% in Latin A and Caribbean KMB-N UMST 2022 41 Adverse effects of mn are: growth failure breakdown of community susceptibility to infection, impairment of mental, motor skills decrease alertness of and physical capacity KMB-N UMST 2022  Causes: decreased intake excessive loss e.g. vomiting and diarrhea increased demands, decreased absorption and utilization (infection) Note there is viscous cycle between infection and MN Social factors also responsible for MN e.g. poverty overcrowding, ignorance, faulty feeding practice, improper weaning KMB-N UMST 2022 43 Spectrum of MN KMB-N UMST 2022 44  Classification of PEM Clinical classification: depends on clinical features e.g. case mainly protein in kw and calories in ms, edema, liver enlargement, skin changes, mental changes, retained fat, all in kw opposite in ms Anthropometric methods of grading a. Welcome's classification b. Gomez classification c. Joliffe's classification d. Waterlow's classification e. Others KMB-N UMST 2022 45  Classification of Protein Energy Malnutrition: PEM is a macronutrient Or: deficiency classified 1. Acute according to indicators 2. Chronic into: 3. Acute on 1. Mild Chronic 2. Moderate The methods of 3. Severe or classification include: a. Kwashiorkor Welcome, WHO ,Gomez, b. Marasmus-Kwashiorkor Welcome classification c. Marasmus.  A. Welcome's classification ❖Age dependant –used for severe PEM based on wt.+ oedema ❖Child actual (x) wt is assessed by a scale, then standard wt. for age of the child (y )is derived from a table x divided by y ×100 to obtain the %. Presence or absence of LL edema is noticed. BODY Wt. % of Edema present Edema absent reference wt for age 80 - 60 Kwashiorkor Under nutrition less than 60 Marasmus- Marasmus Kwashiorkor KMB-N UMST 2022 47  A-Gomez Classification ❖ Based only on wt for age not edema. ❖ Here the reference child is 50th percentile (Boston standard). Accordingly between: 90 -110 normal nutritional status 89 – 75 Ist degree mild mn 75 – 60 2nd degree mn below 60 severe mn KMB-N UMST 2022 48  A-Jelliffe's Classification Also based on wt for age and graded as follows. The reference wt, is 50th percentile value of Harvard standard: Between 90 to 81% Grade I 80 to 71% Grade II 70 to 61 % Grade III below 60% Grade IV KMB-N UMST 2022 49  A- Waterlow's Classification This define 2 types of MN stunting /wasting depending on Ht for age and wt for Ht respectively. Ht for age = current Ht of the child (cm) x100 over Expected Ht for that age ** drop in this ratio indicate stunted growth or chronic MN Wt for Ht = current wt of the child (kg) x100 over Expected wt of the child for that Ht ** drop in this indicate wasting or acute mn (wasting indicate nutritional deprivation of short duration) NB: continued next slide the table KMB-N UMST 2022 50 Nutritional Status % of ht for age - % of wt for ht - stunting wasting normal more than 95 more than 90 mildly impaired or 87.5 - 95 90 - 80 mild Mn moderately 80 – 87.5 80 - 70 impaired or Mn severely impaired less than 80 less than 70 or Mn 51 Mn = Malnutrition KMB-N UMST 2022  OTHERS Indian academy of pediatrics –IAP WHO Classification (Jef index) WHO classification for height for age: also: **MUAC: Useful for 1 to 4 years must not used for under 6 month -MUAC measured by Shakir tape (3colours) in mm -less than 110 mm =severe mn, 110 To 125 = moderate mn. 125 To 135 = at risk of mn More than 125= well nourished KMB-N UMST 2022 52 NB Indian academy of Paed. Depends on wt for age percentage WHO Classification Depends on wt. for ht. index it is independent on age hence it is very useful when age is not known WHO classification for height for age: This method is dependent on age otherwise it is not useful – but useful in assessing chronicity of MN KMB-N UMST 2022 53 ❖Skin Fold By using a caliper (Herpenden ) on Triceps or back of shoulder: Normal 9 – 11 mm MN less than 9 Index of body Wt. ❖Z score ❖= Child wt. minus median Ht (sex age) divided by relevant standard deviation KMB-N UMST 2022 54 International classification of adult BMI under wt less than 18.5 severe thiness less than 16 moderate = 16 - 16.99 NORMAL 18.5 24.99 over wt more or = 25 pre obese 25 – 29.99 obese more or= 30 obese class i 30 – 34.99 obese class ii 35 – 39.99 obese class iii more than 40 KMB-N UMST 2022 55 ❖Advantage of BMI correlates with future health risk and death ❖Limitations of BMI measure of excess wt more than excess fat other factors e.g. age sex ethnicity muscle mass can affect BMI does not distinguish between excess fat and excess muscles bone not related to distribution of body fat older adults tends to have more body fat women have more body fat muscular or athletes tends to have high BMI due to increased body fat NotKMB-N UMST 2022 56 KMB-N UMST 2022 57 KMB-N UMST 2022 58  Lab Investigations 1; urine for sugar + albumin and micro to rule infection 2 urine C/S 3. stool for ova 4. PPD (mantoux) 5. chest x-ray 6. ECG KMB-N UMST 2022 59  Management Rx o underlying inf and infestation o adequate diet o correction of social factors if any o advice for prevention for recurrence : growth monitoring, oral RF ,Immunization, Breast feeding, F planning, health education (diet hygiene etc) KMB-N UMST 2022 60  Prevention Health Promotion: nutritional to pregnant and lactating, correct Breast F, F.Planning, Improvement of living conditions , supplementary feeding Specific protection: rich diet, immunization early Dx and Tx Disability Limitation by intensive Tx and Rehabilitation (nutritional ) KMB-N UMST 2022 61  Malnutrition in SUDAN - Both macro & micro- nutrients def. occur in Sudan - Marasmus is more common than Kwashiorkor - Nutritional Anaemias more common than Iodine def.(West of Sudan) and vit.A def. Assessment of Nutritional status of individuals For this purpose the first 4 groups of indicators are used The value of the indicator is assessed for the individual then compared to the normal value Different classifications can be used according to the indicator measured Assessment of the nutritional status of the community A sample selected is assessed individual by individual as in the assessment of individual above The individuals comprising the sample are then grouped in different classifications Relative frequency for each classification is then calculated to represent the status of the whole population After assessment of the community is done Management then follows: Decision for management of the community is based on prevalence of moderate to severe malnutrition. 3 plans are suggested: PLAN 1: If the prevalence of PEM is 20% 0r above or if it is 10% to 19% with presence of risk factors. In this case plan one is used which include: Plan 1: a. Total coverage of population with general ration distribution offering 170 Kcal per capita, in addition to b. Supplementary feeding program for at risk to ensure their daily requirements, and c. Therapeutic feeding for severely malnourished to treat them KMB-N UMST 2022 66 PLAN 2: If the prevalence is 10 % to 19% without risk Factors or if it is 5% to 9% with risk factors then plan 2 is used which include: * Supplementary feeding for at risk, and * Therapeutic feeding for severely malnourished PLAN3: If the prevalence is less than 10% without risk factors plan3 which is to treat cases i.e. only threaputic feeding is recommended. The risk factors stated above include: Mortality rate above 1/10000 per day Food shortage leading to daily intake less than the required for individuals Presence of an epidemic of measles or diarrhera Cold weather and unsuitable shelter The at risk groups include: under 5 – orphan or unaccompanied minors – pregnant – Lactating – the elderly Thank You KMB-N UMST 2022 70 INTEGRATED MANAGEMENT OF CHILD HEALTH IMCI  Introduction and Concept the IMCI consist of providing quality care to sick children which is serious challenge. WHO and UNICEF have addressed this challenge by developing strategy called Integrated Management of Childhood Illness (IMCI) What is IMCI? It is integrated approach to child health that focus on wellbeing of the whole child. IMCI aim at reduce death illness and disability KMB-N UMST 2022 72 and to promote growth and development among children under 5 years of age. IMCI includes both preventive and curative elements that are implemented by families and communities as well as health facilities. The strategy include: Improving case management skills of health care staff Improving overall health system Improving family and community health practice KMB-N UMST 2022 73 In health facilities the IMC strategy promotes accurate identification of childhood illnesses in outpatient setting, ensure appropriate combined Tx of all major illnesses, strengthen counselling of caretakers, and speed up the referral of severely ill children. In home setting, to promotes appropriate care seeking behaviors, improved nutrition and preventative care, and the correct implementation of prescribed care. KMB-N UMST 2022 74 Why is IMCI better than single condition approaches? Children brought for medical Tx in developing cs are often suffering from more than one condition, making a single Dx impossible. IMCI is an integrated strategy. which take into account the variety of factors that put children at serious risks. It ensures the combined Tx of major childhood illnesses emphasizing prevention of disease through immunization and improved nutrition KMB-N UMST 2022 75  Common childhood illnesses Sore throat Ear pain UTI Skin infection Bronchitis Bronchiolotis Pain Common cold KMB-N UMST 2022 76  Killers of childhood Diphtheria Measles and Rubella Pertussis Tuberculosis Tetanus Polio KMB-N UMST 2022 77  History The Integrated Management of Child Illness (IMCI) strategy was introduced in 1996. 27-Aug-24 phc-rad 78  – The strategy has changed (2002) into the Integrated Management of Child Health – While still retaining its original acronym “IMCI”. 27-Aug-24 phc-rad 79  OBJECTIVE OF IMCI TO REDUCE U5 CHILD MORTALITY AND MORBIDITY 27-Aug-24 phc-rad 80  ACTIVITIES OF IMCI Improving the performance and quality of health workers. (FIRST COMPONENT) Improving family and community care practices. (SECOND AND THIRD COMPONENT) 27-Aug-24 phc-rad 81 Family and community practices (SECOND AND THIRD COMPONENTS) 1. Breastfeeding (exclusive up to 6 months) 2. Complementary feeding (6 months - 2 years or longer) 3. Micronutrients in diet or supplementation 27-Aug-24 phc-rad 82 4. Hygiene 5. IMMUNIZATION. 6. PROTECTION FROM MALARIA 27-Aug-24 phc-rad 83 7. PSYCHOSOCIAL DEVELOPMENT. 27-Aug-24 phc-rad 84