Prof.Dr.Selma KARABEY

1. Importanceof NutritionPrinciplesof BalancedDietMeasuringNutritionalStatusandNutritionalDisorders Prof.Dr.Selma KARABEY

2. Nutrition: “TheGood, theBad, andtheUgly” • Nutrition is the intake of food, considered in relation to the body’s dietary needs. • Good nutrition – an adequate, well balanced diet combined with regular physical activity – is a cornerstone of good health. • Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

5. BalancedDiet • An unhealthy diet is one of the major risk factors for a range of chronic diseases, including cardiovascular diseases, cancer, diabetes and other conditions linked to obesity. • Specific recommendations for a healthy diet include: eating more fruit, vegetables, legumes, nuts and grains; cutting down on salt, sugar and fats. • It is also advisable to choose unsaturated fats, instead of saturated fats and towards the elimination of trans-fatty acids.

6. BalancedDiet-2 For diet, recommendations for populations and individuals should include the following: • achieve energy balance and a healthy weight • limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids • increase consumption of fruits and vegetables, and legumes, whole grains and nuts • limit the intake of free sugars • limit salt (sodium) consumption from all sources and ensure that salt is iodized

7. NutritionalElements • Protein 10-20% • Carbohydrate50-70% • Fat20-30% • Vitamins • Minerals • Water

8. Specialgroupsfornutrition • Infantsandyoungchildren • Schoolagechildren • Fertilewomen • Pregnants • Breastfeeding • Elderly • Handicappedpeople

13. Carbohydrates • Carbohydrates are our body's main energy source. • Ourbrain is fueled by carbohydrates. • Carbohydrates occur in a variety of forms: simple sugars, more complex starches and fiber. • They are found naturally in legumes, grains, vegetables, fruits and milk. They're also added to baked goods and many other foods.

14. Carbohydrates • Wehavetoget 45 to 65 percent of our daily calories from carbohydrates. • Carbohydrates have 4 calories a gram. • Based on a 2,000-calorie-a-day diet, this amounts to 900 to 1,300 calories a day, or about 225 to 325 grams.

15. Carbohydrates Fiber; • Fiber is the part of plant-based foods that our body doesn't digest and absorb. There are two basic types of fiber: soluble and insoluble. • Soluble fiber may help improve our cholesterol and blood sugar levels. Oats, dried beans and some fruits, such as apples and oranges, are good sources of soluble fiber. • Insoluble fiber adds bulk to our stool and can help prevent constipation. Vegetables, wheat bran and other whole grains are good sources of insoluble fiber.

16. Carbohydrates Sugar • All sugar, whether natural or processed, is a type of carbohydrate that our body uses for energy. • Sugar occurs naturally in some foods, including fruits, vegetables, milk and some grains. • Sugar is also added to foods and beverages. These added sugars do little more than add calories to our diet. Many processed foods that have added sugar also contain solid fats.

17. Protein • Protein is an important nutrient, essential for growth and development. • All the cells of our body include protein. • Protein is also an important source of calories and energy. • Both plant-based and animal-based foods provide protein.

18. Fats • Fats aren't necessarily bad for us. • Dietary fat is a nutrient that helps our body absorb essential vitamins, maintains the structure and function of cell membranes, and helps keep our immune system working. • Some types of fat, though, may increase our risk of heart disease and other health problems. • Fat also has a lot of calories, increasing the risk of weight gain.

19. Fats Saturated fat • Saturated fat is most often found in animal products, such as cheese, red meat, poultry, butter and whole-milk products. • Other foods high in saturated fat include those made with coconut, palm and other tropical oils. • Saturated fat may increase our risk of heart disease and type 2 diabetes. • Wehaveto limit saturated fat to no more than 10 percent of our total calories

20. Fats • Trans fat • Trans fat occurs naturally in some foods, especially foods from animals. But most trans fat is created during food processing through partial hydrogenation of unsaturated fats. • Trans fat is found in some types of margarine, shortening, snack foods and commercial baked goods. • Trans fat can increase our risk of heart disease.

21. Cholesterol • Cholesterol is vital because it helps build our body's cells and produces certain hormones. • But our body makes enough cholesterol to meet its needs — wedon't need any dietary cholesterol. • Excessive cholesterol in our diet can increase our risk of heart disease and stroke. • Dietary cholesterol comes from animal products, such as meat, poultry, seafood, eggs, butter and other dairy products.

22. Sodium • Some sodium is vital because it helps maintain the right balance of fluids in our body, helps transmit nerve impulses, and influences the contraction and relaxation of muscles. • Too much sodium, though, can be harmful, increasing our blood pressure and the risk of heart disease and stroke.

23. Direct Methods of Nutritional Assessment Nutrition is assessed by two types of methods; direct and indirect. The direct methods deal with the individual and measure objective criteria, while indirect methods use community health indices that reflects nutritional influences.

24. Direct Methods of Nutritional Assessment-2 These are summarized as ABCD • Anthropometric methods • Biochemical, laboratory methods • Clinical methods • Dietary evaluation methods

25. Indirect Methods of NutritionalAssessment These include three categories: • Ecological variables including crop productio • Economic factors e.g. per capita income, population density andsocial habits • Vital health statistics particularly infant andunder 5 mortality andfertility index

26. MeasuringNutritionalStatus

27. Anthropometric Methods • Anthropometry is the measurement of body height, weight and proportions. • It is an essential component of clinical examination of infants, children andpregnant women. • It is used to evaluate both under andover nutrition. • The measured values reflects the current nutritional status anddon’t differentiate between acute andchronic changes .

29. Other anthropometric Measurements • Mid-arm circumference • Skin fold thickness • Head circumference • Head/chest ratio • Hip/waist ratio

30. Measurements for adults Height: The subject stands erect andbare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault andheight is recorded to the nearest 0.5 cm. Weight Measurement • Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable. • Weigh in light clothes, no shoes • Read to the nearest 100 gm (0.1kg)

31. Nutritional Indices in Adults • The international standard for assessing body size in adults is the body mass index (BMI). • BMI is computed using the following formula: BMI = Weight (kg)/ Height (m²) • Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity andmortality

32. BMI (WHO - Classification) • BMI < 18.5 = Under Weight • BMI 18.5-24.5= Healthy weight range • BMI 25-30 = Overweight (grade 1obesity) • BMI >30-40 = Obese (grade 2 obesity) • BMI >40 =Very obese (morbid or grade 3 obesity)

33. Waist/Hip Ratio • Waist circumferenceis measured at the level of the umbilicus to the nearest 0.5 cm. • The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together. • The measurement should be taken at the end of a normal expiration.

34. Waist circumference • Waist circumference predicts mortality better than any other anthropometric measurement. • It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identified MALES FEMALE LEVEL 1 > 94cm > 80cm LEVEL2 > 102cm > 88cm

35. Hip Circumference • is measured at the point of greatest circumference around hips andbuttocks to the nearest 0.5 cm. • The subject should be standing and the measurer should squat beside him. • Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.

36. Interpretation of WHR • High risk WHR= >0.80 for females and=>0.95 for males • Indicatescentral (upper body) obesity and is considered high risk for diabetes andCVS disorders. • A WHR below these cut-off levels is considered low risk.

37. DIETARY ASSESSMENT • Nutritional intake of humans is assessed by five different methods. These are: • 24 hours dietary recall • Food frequency questionnaire • Dietary history since early life • Food dairy technique • Observed food consumption

38. 24 Hours Dietary Recall • A trained interviewer asks the subject to recall all food anddrink taken in the previous 24 hours. • It is quick, easyanddepends on short-term memory, but may not be truly representative of the person’s usual intake.

39. Food Frequency Questionnaire • In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency andquantity) per day, per week andper month. • Inexpensive, more representative andeasy to use.

40. DIETARY HISTORY • It is an accurate method for assessing the nutritional status. • The information should be collected by a trained interviewer. • Details about usual intake, types, amount, frequency andtiming needs to be obtained. • Cross-checking to verify data is important.

41. FOOD DAIRY • Food intake (types andamounts) should be recorded by the subject at the time of consumption. • The length of the collection period range between 1-7 days. • Reliable but difficult to maintain.

42. Observed Food Consumption • The most unused method in clinical practice, but it is recommended for research purposes. • The meal eaten by the individual is weighed and contents are exactly calculated. • The method is characterized by having a high degree of accuracy but it’sexpensive ,alsoneeds time andefforts.

43. Interpretation of Dietary Data 1. Qualitative Method • Using the food pyramid andthe basic food groups method. • Different nutrients are classified into 5 groups (fat andoils, bread andcereals, milk products, meat-fish-poultry, vegetables andfruits) • Determinethe number of serving from each group andcompare it with minimum requirement.

44. Interpretation of Dietary Data/2 2. Quantitative Method • The amount of energy andspecific nutrients in each food consumed can be calculated using food composition tables andthen compare it with the recommended daily intake. • Evaluation by this method is expensive andtime consuming, unless computing facilities are available.

45. Initial Laboratory Assessment • Hemoglobin estimation is the most important test,anduseful index of the overall state of nutrition. Besides anemia,it also tells about protein andtrace element nutrition. • Stool examination for the presence of ova and/or intestinal parasites • Urine dipstick andmicroscopy for albumin, sugar and blood

46. References • Oxford Textbook of PublicHealth, FoodandNutrition, RogerDetels, Robert Beaglehole, Mary AnnLansang, Martin Gulliford, Oxford UnivercityPress, 2009 • IMPROVING CHILD NUTRITION, The achievable imperativefor global progress, United Nations Children’s Fund (UNICEF)April 2013 • Global nutritionpolicyreview:Whatdoes it taketo scale up nutrition action?World HealthOrganization 2013 • EssentialNutritionActions: improvingmaternal, newborn, infantandyoungchildhealthandnutrition, World HealthOrganization2013 • WHO childgrowthstandardsandtheidentificationof severe acutemalnutritionin infantsandchildren, A JointStatement bythe World HealthOrganizationandthe United Nations Children’sFund, World Health Organization and UNICEF 2009 • Infant and young child feeding : model chapter for textbooks for medical studentsandalliedhealthprofessionals, World HealthOrganization2009 • Halk Sağlığı Temel Bilgiler, Toplum Beslenmesi, Prof.Dr.Çağatay Güler, Prof.Dr.Levent Akın, Hacettepe Üniversitesi Yayınları 2012

47. Web Sources • Healthy diet: Do you follow dietary guidelines?,Dr.JohnNoseworthy, http://www.mayoclinic.com/health/how-to-eat- healthy/MY02264/NSECTIONGROUP=2 (lastaccessdate: 11.12.2013) • Assessment of NutritionalStatus, AbdelazizElamin, Collage of Medicine Sultan QaboosUniversity, Omanhttp://www.pitt.edu/~super7/19011.../19801.ppt (lastaccess date:12.11.2013)