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WHAT IS PUBLIC HEALTH NUTRITION? Problems related to inadequate quantity and quality of the habitual diet - PowerPoint PPT Presentation

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WHAT IS PUBLIC HEALTH NUTRITION? Problems related to inadequate quantity and quality of the habitual diet Problems related to excessive intake of quantity of the habitual diet Food-related problems and food safety that affect the

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  • Problems related to inadequate quantity and quality of

  • the habitual diet

  • Problems related to excessive intake of quantity of the

  • habitual diet

  • Food-related problems and food safety that affect the

  • health and function of a large percent of the general

  • population

  • Nutrition problems prevented or ameliorated by

  • identification of risk factors and early detection by

  • screening when feasible, in contrast to only specific

  • nutrient treatment

  • Global warming, as well as natural disasters (flooding,

  • droughts, etc.)

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Will focus on interconnected areas of the world (global

Outlook) -- the Nutrition Transition

Developing countries with predominately poor people plus an increasingly wealthy, middle-class, urbanized population with adaptation of physical activity, stress, etc.), over-nutrition with high-energy diets, alcohol, high intake of refined sugars, etc.


Industrialized, wealthy countries with growing disadvantaged populations with growing food security, income and hunger and malnutrition

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Political-cultural Geographic-climatic

CNL Socioeconomic Food Aspects of health

= factors considerations (contributory

(economic, infections,

education) environmental

hygiene, health-

related services)

___________________________________________ Demographic Issues

Community nutrition level (CNL) ‘equation’

*Especially vulnerable groups

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  • Socio-economic factors

    • Poverty, Education level, and Government policies, etc.

  • Food considerations

    • Availability and accessibility

    • Consumption, Utilization

    • Adequacy- quantity and quality

  • Aspects of health

    • Co-existing infections and health-related services

    • Environmental sanitation

  • Demographic issues

    • Family size

  • Geographic and climactic influences

    • Global warming, flooding, drought, etc.

  • Civil upheaval and strife

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  • Food intake above physiological needs for

  • normal function and growth in children

  • Intake of vitamins, minerals and other

  • micronutrients far in excess of nutritional needs


  • Fast food addiction and calorie-dense snacks

  • Megadoses of vitamins and other

    micronutrients and “natural supplements”

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  • Low quantity of food for requirements

  • Low density of specific nutrients

  • Poor absorption of nutrients

  • - High phytate and fiber content of plant-based diets

  • - Competition of nutrients (i.e., iron and zinc)

  • Infection and intestinal parasites

  • Malabsorption due to enzyme deficiencies, structural

  • damage to intestinal surfaces

  • Drug-nutrient interactions, etc.

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Childhood obesity leads to adult obesity

Type II diabetes

Complications: cardiac morbidity

Retinal with blindness

Gangrene- i.e. amputations

Elevated cholesterol and triglycerides

Risk factors for cardiovascular diseases

Limited access to healthy foods, facilities, and environment for physical activity

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  • PROTEIN-ENERGY MALNUTRITION, from mild to severe

    • KWASHIORKOR (protein deficiency)

      • Low-serum albumin with edema (hair discoloration and burn-like skin lesions)

      • Severe apathy and lethargy

      • Often precipitated by measles or other severe infection

      • Impaired immune function with high infection complications

      • Rapid reversal to normal after two weeks with high protein/energy diet

      • Return of immune function to normal

    • MARASMUS (total energy depletion)

      • Seen in both young children and adults

      • Children alert, ravenous, and irritable

      • Often seen with HIV/AIDS, tuberculosis, malignancies, etc.

      • High energy and protein diet required over many months for recovery

      • Major risk factors: early weaning under 6 mos with poor breast milk substitute

      • Cognitive impairment

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  • (and to a lesser degree, in the industrialized nations)

  • The principal public health nutrition problems

  • Maternal malnutrition in preconception period and pregnancy:

  • Poor pregnancy weight gain, and depletion of meager

  • nutrient stores (fat and muscle mass, iron, calcium, zinc, vitamin A, etc.)

    • Women “eat down” hoping to have a small baby for easier delivery

  • Maternal anemia, small pelvic outlet from earlier rickets, or protein energy

  • malnutrition

  • Low birth weight: small for dates (i.e., low BW term newborns)

  • high mortality, CNS damage, poor resistance to infection, risk for adult CV and diabetes

  • Breast milk may be deficient in vitamins (B12 ,folate, A, and other deficiencies) and quantity if severely malnourished

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  • Exclusive breast feeding (EBF) for first 4-6 months

    • Those not EBF have double the IMR compared to breast fed infants in developing countries

  • Breast milk

    • Sterile with multiple anti-infective properties

    • Nutrients tailored to needs and developmental stage of infant

    • Promotes brain and visual development

    • Growth-stimulating factors of digestive tract

    • Psychological benefits for maternal infant pair

    • Few safe alternatives

    • Enhances child spacing:

      • Suppresses ovulation —but imperfectly

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  • Continue breast feeding until 2+ years child

  • Need for energy-dense food (small stomachs!) with high-quality complete protein, energy, and micronutrients

    • Iron, zinc, iodine, calcium, particularly vitamins A, D, B12

    • Supplied by local beans, cereals, dairy products, and need for modest amounts of animal foods

  • For vitamins C and A, use of green and orange vegetables and fruits

  • *NOTE: Death rates around weaning time 30-50-fold higher in developing countries than in rich nations, due to combination of malnutrition and infection

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Iron deficiency

  • Anemia

  • Impaired cognitive function

  • Decreased physical activity

  • Decreased work capacity in older children and adults

  • Decreased appetite

  • Impaired immune function

    Animal source foods needed- iron absorption from cereals and legumes increased when mixed with meat (any type)

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Vitamin A deficiency THE “EMERGING NATIONS”

  • Irreversible blindness

  • Increased morbidity and mortality from infection, esp. pneumonia and diarrhea

  • Loss of structure and function of epithelial cells of the body

  • Impaired cellular immune function

    Sources: preformed retinol from animal source foods - carotene from orange yellow red F and V

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Zinc deficiency (part of many enzyme systems) THE “EMERGING NATIONS”

  • Stunting with deficiency

  • Loss of appetite; loss of taste

  • Lowered resistance to infection

  • Delayed puberty

  • Impaired wound healing

  • Decreased activity


    Animal source foods - cereal legumes mixed with meat and vitamin C will enhance absorption

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  • Seen in vegetarians, or those on low animal source foods

  • Key role

    • Brain and CNS development

    • Red blood cell formation

    • Immune function

  • Role in brain development and cognitive function in children

  • Low breast milk B12 is of risk to an infant

  • Approach: Promote animal source foods in diet, containing milk and/or meat

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Folic acid neural deficiency THE “EMERGING NATIONS”

  • Neural tube defects from deficient intake in first trimester of pregnancy

  • Needed before the woman realizes she is pregnant (policy is for all young women to take 400 micrograms of folic acid daily)

  • Anemia (macrocytic)

  • Sources: orange juice, meat (especially organ parts), dark green leafy vegetables

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Calcium deficiency THE “EMERGING NATIONS”

  • Bone calcification

  • Needed early and throughout life to prevent osteoporosis

  • Prevents rickets post-weaning, even in tropics

  • Prevents hypertension (especially in pregnancy)

    Source: milk products, small fish

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Vitamin D deficiency THE “EMERGING NATIONS”

  • Vitamin D deficiency, now known to be widespread globally, including the U.S. and Europe

    • At risk groups: those with dark skin, and limited exposure of all to sunlight (fear of melanoma)

    • Older recommendations for Vitamin D extremely low

    • Sub-clinical and clinical rickets now seen in northern, tropical, and extremely southern latitudes throughout the world

    • Vitamin D plays a vital role in protection against malignancy, immune abnormalities, and other body functions (under active research)

    • Widespread need for supplementation

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  • Iodine deficiency THE “EMERGING NATIONS” still a significant global problem, with negative socioeconomic impact

    • Impaired intellectual capacity, decreased productivity, and initiative

  • Significant cause of poor pregnancy outcome, severely mentally and physically retarded infants, children, and adults

  • Globally due to lack of iodine in the food, soil, and water supply

    • Seen in land areas away from the sea

    • Highly prevalent in mountainous areas receiving water from melted snow and ice

    • Entire food chain also affected with low iodine content

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Manifestations of iodine deficiency THE “EMERGING NATIONS”

  • High pregnancy wastage, appearance of goiters in pregnant women, teenage girls > boys

  • Severely affected infant at birth with cretinism

    • Severe growth and mental retardation- irreversible

      Less severe forms of iodine deficiency

    • Poor growth and development

    • Poor school performance, and varying degrees of mild mental retardation

    • Poor pregnancy outcome

      Main approaches

    • Iodization of salt, universally

    • If commercial water not available, drops of iodine placed in household or school drinking water

    • Or iodine injections in oil annually or more frequently by oral pills

      Still an unsolved, but greatly improved, problem calling for collaboration between local populations, industry, and government

      In U.S.A., iodine deficiency most due to metabolic errors or thyroid disease, rather than iodine deficiency

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Different public health approaches to modifying intake in the prevention and control of micronutrient deficiencies


Dietary diversification

  • Home gardening of high carotenoid varieties of F&V

  • Intensive nutrition education

  • Raising of small animals for milk, meat, and eggs for household consumption

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Micronutrient Fortification the prevention and control of micronutrient deficiencies(where feasible and affordable)

  • Sugar, flour, margarine, edible oils, noodles, condiments, etc.

    Supplementation (particularly in developing countries)

  • National immunization days and micronutrient distribution days

  • Distribution through health centers, targeting mothers and children

  • Postpartum supplementation

  • Vitamin A capsule distribution programs in developing countries (mega-doses every 6 months for children under 5)

  • Development of Sprinkles

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Childhood Obesity- U.S. the prevention and control of micronutrient deficiencies

Source: www.cdc.gov/obesity

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Childhood Obesity - World the prevention and control of micronutrient deficiencies

*5-15y for girls

Source: International Obesity Taskforce, 2010 (http://www.iotf.org/database/documents/GlobalChildhoodOverweightMay2010.pdf)

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Comments on childhood obesity the prevention and control of micronutrient deficiencies

  • Staggering economic and health burden of obesity in the U.S.A.

    • Proportionately high prevalence in lower socioeconomic groups i.e. Hispanic, African-American, and Native American populations

      • Poor neighborhoods

        • Few safe parks or recreation areas for physical activity

        • Lacking in affordable food stores with nutritious, low-calorie foods, and abundance of fast food and junk food stores

      • School food services- Improvements being made

        • Salad bars, removal of vending machines and junk food

      • Type II Diabetes widespread in all obese groups, but now even in preteen children

      • Multiple, but inadequate, numbers of school and community programs are increasing

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Nutrition transition in developing countries the prevention and control of micronutrient deficiencies

  • Double burden of malnutrition and over-nutrition and obesity in urban areas of developing countries

  • Change in lifestyle and shift to cash economy, with movement to urban areas

    • Cash economy: cannot grown own food; heavy reliance on high fat, high energy street foods

    • Poor access to fresh fruits and vegetables, and milk

    • Decreased physical labor and physical activity in urban settings

    • Increasing cardiovascular diseases with obesity, diabetes

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Fetal programming and origins of adult chronic disease the prevention and control of micronutrient deficiencies

  • The Barker Hypothesis

    • Intrauterine malnutrition with low-birth weight in numerous epidemiological studies, associated with increased risks of coronary heart disease, stroke, hypertension, and type II diabetes in surviving adults

    • Effects may be due to “fetal programming,” presumably due to insult at critical, sensitive periods in fetal development

      • Permanent adverse effects on structure, physiology, metabolism, and hormonal function

    • Adaptations invoked by maternal placental failure of nutrient supply to meet fetal demand

    • Maternal malnutrition before and during pregnancy of key importance, and under active research (possible inter-generational effects)