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Major Health Problems Plants: Green leafy vegetables

Breastmilk is a rich source of Vit.A
• Protein-Energy Malnutrition (PEM) and
Signs and Symptoms:
• Micronutrient Deficiencies (VAD,IDA,IDD) Early symptom: nyctalopia or nightblindness
First clinical sign: Xerosis conjunctivae
1998 FNRI National Nutrition Survey Bitot’s spots
□ Pre-Schoolers:
0.2% moderately underweight Corneal xerosis/ xerophthalmia
5.4% stunted Corneal ulcers
7.2% wasted
□ Schoolchildren Blindness
8.3% moderately underweight
5.8% stunted Skin: Generalized dryness
8.7%wasted Diagnosis:
□ Highest prevalence is among 1 year old at 14.2% Serum retinol levels ,20 ug/dL (WHO)
□ Prevalence rate of anemia for all age group is 30.6% Impression cytology
□ 36 out of 100 children (35.39%) have moderate to Treatment:
severe IDD If with active eye lesion:
Ø 200,000 I.U. immediately
Ø1991 Survey Ø 200,000 next day
□ 10 out of 100 (10. %) children aged 6 months to 6 Ø 200,000 I.U. within next 14 days
years have VAD Prevention:
□ 3-4 out of 100 children (35. 39%) children have Vitamin A supplementation
deficient to low serum Vit.A Pre-schoolers: 200,000 i.u. p.o. every 4-6
months
COMMON NUTRITIONAL DISORDERS < 1 year old =give ½ dose
• Protein-Energy Malnutrition (PEM)
• Protein-Calorie Malnutrition IRON DEFICIENCY (IDA)
-can be attributed to: Normal Hgb levels (WHO):
Ÿ lack of adequate food Ø 6 months- 6 years old 11 gms/dL
Ÿ wrong beliefs and practices Ø 6.1 to 14 year old 12 g/dL
Ø Adult male 13 g/dL
FACTORS AFFECTING NUTRITIONAL STATUS OF THE Ø Non-lactating/nonpregnant
FILIPINO CHILD Ø female 12 g/dL
Ø Pregnant female 11 g/dL
child blood and nutritional child health status Ø Lactating female 12 g/dL
intake Causes:
food and nutrition intake of Child feeding practice • Blood Loss
household • Demand of fetus and placenta
Food demand function Food supply function
• Intestinal Parasitism
• Food Threshold • Food production
• Income • Food supply • Malaria
• Occupation available • Schistosomiasis
• Education of for consumption • Low intake of heme iron
Mother Signs and Symptoms:
• Food prices • Pallor: most important clue
• Hgb <5 g/dL
Vitamin A Deficiency • Irritability
Sources of Vit. A: • Anorexia
Animal: best source is liver

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
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• Tachycardia • PEM can be sudden and total (starvation) or

• Systolic murmur gradual.
• Severity ranges from subclinical deficiencies
Lab: to obvious wasting (with edema, hair loss, and
• Decrease serum ferritin levels skin atrophy) to starvation.
• decrease Hgb • Multiple organ systems are often impaired.
• microcytosis,hypochloremia, poikilocytosis • Diagnosis usually involves laboratory testing,
Treatment: including serum albumin.
• FeS04 6 mgs/kg/day • Treatment consists of correcting fluid and
• Vitamin C =enhances absorption electrolyte deficits with IV solutions, then
• Diet : Heme iron is better absorbed gradually replenishing nutrients, orally if
possible.
Iodine DeficiencyDISORDER (IDD)
Goiter –compensatory mechanism. Female more PEM
commonly affected. ØIn developed countries PEM:
ü is common among the institutionalized elderly
Common in mountainous areas: (although often not suspected) and
Causes irreparable damage to fetal brain ü among patients with disorders that decrease
Goitrogenic Food appetite or impair nutrient digestion, absorption, or
-Cassava, cabbage, cauliflower, red –skinned peanuts, metabolism.
bamboo shoots, carrots, radish Ø In developing countries
ü PEM affects children who do not consume
Classification of Endemic Goiter enough calories or protein.
Grade Description
0 gland not abnormally enlarged PEM GRADING
14 gland enlarged but not visible with PEM is graded as:
neck extended 1. mild
13 gland enlarged and visible only with 2. moderate or
neck extended 3. severe.
2 goiter visible with head in normal
position Ø Grade is determined by calculating weight as a
3 goiter easily visible from a distance percentage of expected weight for length or height
using international standards:
Epidemiology Criteria For Assessing Severity of IDD
Median value (ug / L) Severity of IDD ünormal………. 90 to 110%;
<20 Severe IDD ü mild PEM…... 85 to 90%;
20-49 Moderate IDD ü moderate…… 75 to 85%;
50-99 Mild IDD ü severe……..< 75%;
> 100 No deficiency
Classification and Etiology
Tx:
• mild Iodine deficiency + iodized salt PEM may be
• iodine rich food
• iodine oil capsule (200 mgs. K iodate) 1. primary or
• Lipcodol 1 cc injection (lasts 3-4 years)
Prevention: 2. secondary.
Breastfeeding üPrimary PEM:
Iron-rich food -is caused by inadequate nutrient
Avoid goitrogens intake.
ü Secondary PEM:
Protein-Energy Malnutrition -results from disorders or drugs
• Protein-energy malnutrition (PEM), or protein- that interfere with nutrient use.
calorie malnutrition, is an energy deficit due to
chronic deficiency of all macronutrients. I. Primary PEM:
• It commonly includes deficiencies of many Worldwide, primary PEM occurs
micronutrients. ümostly in children

üand the elderly who lack access to nutrients,
Ø although a common cause in the elderly is
depression.
Ø It can also result from fasting or anorexia nervosa.
ØChild or elder abuse may be a cause
3 COMMON FORMS of PEM:
ØThe form depends on the balance of nonprotein
and protein sources of energy
ØIn children, chronic primary PEM has three
common forms:
1. marasmus,
2. kwashiorkor, and
3. marasmic- kwashiorkor: a form with
characteristics of both.
Ø Starvation is an acute severe form of primary
PEM.
1. Marasmus (also called the dry form of PEM)
causes weight loss and depletion of fat and muscle.
Ø In developing countries, marasmus is the most
common form of PEM in children.
2. Kwashiorkor
Ø also called the wet, swollen, or edematous form
üIs associated with premature abandonment
of breastfeeding, which typically occurs when a
younger sibling is born, displacing the older child
from the breast.
üSo children with kwashiorkor tend to be older
than those with marasmus.
ü May also result from
Ÿ an acute illness, often gastroenteritis
Ÿ or another infection (probably secondary to
cytokine release), in a child who already has
PEM
Ÿ low percentage of breastfeeding
Ÿ wrong weaning practices
Ÿ low consumption of oil
Treatment: Milk, sugar, oil
üA diet that is more deficient in protein than energy
may be more likely to cause kwashiorkor than
marasmus.
ü Less common than marasmus, kwashiorkor tends
to be confined to specific parts of the world, such as
rural Africa, the Caribbean, and the Pacific islands. In
these areas, staple foods (eg, yams, cassavas, sweet
potatoes, green bananas) are low in protein and high
in carbohydrates.
ü In kwashiorkor, cell membranes leak, causing
extravasation of intravascular fluid and protein,
resulting in peripheral edema.
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3. Marasmic kwashiorkor :
Øis characterized by features of marasmus and
kwashiorkor.
Ø Affected children have some edema and more
body fat than those with marasmus.
Starvation :
Ø is a complete lack of nutrients.
Ø It is occasionally voluntary (as in fasting or
anorexia nervosa) but usually due to external factors
(eg, famine, wilderness exposure).
II. Secondary PEM:
This type most commonly
1. results from disorders that affect GI function,
2. wasting disorders, and
3. conditions that increase metabolic demands
eg,
ü infections,
ü hyperthyroidism,
ü Addison's disease,
ü pheochromocytoma,
ü other endocrine disorders,
ü burns,
ü trauma,
ü surgery,
ü other critical illnesses).
Ø In wasting disorders (eg, AIDS, cancer) and renal
failure, catabolism causes cytokine excess,
resulting in undernutrition.
Ø End-stage heart failure can cause cardiac
cachexia, a severe form of undernutrition;
Ø mortality rate is particularly high.
Ø Wasting disorders can decrease appetite or
impair metabolism of nutrients.
Ø Disorders that affect GI function can interfere with
digestion (eg, pancreatic insufficiency), absorption
(eg, enteritis, enteropathy), or lymphatic transport
of nutrients (eg, retroperitoneal fibrosis, Milroy's
disease).
PATHOPHYSIOLOGY
Ø The initial metabolic response is decreased
metabolic rate. To supply energy, the body
first breaks down adipose tissue. However,
later, visceral organs and muscle also are
broken down and decrease in weight. Loss of
organ weight is greatest in the liver and
intestine, intermediate in the heart and
kidneys, and least in the nervous system.
SYMPTOMS AND SIGNS:
ØSymptoms of moderate PEM can be constitutional
or involve specific organ systems.
ü Apathy and irritability are common.
üThe patient is weak, and work capacity
decreases.

üCognition and sometimes consciousness are
impaired.
üTemporary lactose deficiency and achlorhydria
develop.
üDiarrhea is common and can be aggravated by
deficiency of intestinal disaccharidases,
especially lactase (see Malabsorption Syndromes:
Etiology).
üGonadal tissues atrophy.
ü PEM can cause amenorrhea in women and
loss of libido in men and women.
Ø Wasting of fat and muscle is common in all
forms of PEM. In adult volunteers who fasted
for 30 to 40 days, weight loss was marked
(25% of initial weight). If starvation is more
prolonged, weight loss may reach 50% in
adults and possibly more in children.
Ø Wasting (called cachexia in adults) is most
obvious in areas where prominent fat depots
normally exist. Muscles shrink and bones
protrude. The skin becomes thin, dry,
inelastic, pale, and cold. The hair is dry and
falls out easily, becoming sparse. Wound
healing is impaired. In elderly patients, risk of
hip fractures and decubitus ulcers increases
Ø With acute or chronic severe PEM, heart size
and cardiac output decrease; pulse slows and
blood pressure falls. Respiratory rate and vital
capacity decrease. Body temperature falls,
sometimes contributing to death. Edema,
anemia, jaundice, and petechiae can develop.
Liver, kidney, or heart failure may occur.
Ø Cell-mediated immunity is impaired,
increasing susceptibility to infections.
üBacterial infections (eg, pneumonia,
gastroenteritis, otitis media, UTIs, sepsis) are common
in all forms of PEM
. ü Infections result in release of cytokines, which
produce anorexia, worsen muscle wasting, and cause
a marked decrease in serum albumin levels.
Ø Marasmus in infants causes hunger, weight
loss, growth retardation, and wasting of
subcutaneous fat and muscle.
ü Ribs and facial bones appear prominent. Loose,
thin skin hangs in folds.
Ø Kwashiorkor is characterized by peripheral
edema.
ü The abdomen protrudes, but there is no ascites.
ü The skin is dry, thin, and wrinkled; it can become
hyperpigmented and fissured and later
hypopigmented, friable, and atrophic.
ü Skin in different areas of the body may be
affected at different times.
ü The hair can become thin, reddish brown, or gray.
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ü Scalp hair falls out easily, eventually becoming
sparse, but eyelash hair may grow excessively.
ü Alternating episodes of undernutrition and
adequate nutrition may cause the hair to have a
dramatic “striped flag” appearance.
ü Total starvation is fatal in 8 to 12 wk. Thus, certain
symptoms of PEM do not have time to develop. be
apathetic but become irritable when held.
DIAGNOSIS
Ø Diagnosis can be based on history when
dietary intake is markedly inadequate. The
cause of inadequate intake, particularly in
children, needs to be identified. In children
and adolescents, child abuse and anorexia
nervosa should be considered.
Ø Physical examination findings can usually
confirm the diagnosis.
Ø Laboratory tests are required to identify
causes of secondary PEM.
üMeasurement of plasma albumin,
ü total lymphocyte count, CD4+ T lymphocytes,
and
ü response to skin antigens may help determine
the severity of PEM (see Table 3: Undernutrition:
Values Commonly Used to Grade the Severity of
Protein-Energy Malnutrition )or confirm the diagnosis
in borderline cases.
ü Measurement of C-reactive protein or soluble
interleukin-2 receptor should be measured when the
cause of undernutrition is unclear ; these
measurements can help determine whether there is
cytokine excess.
üMany other test results may be abnormal: eg,
decreased levels of hormones, vitamins, lipids,
cholesterol, prealbumin, insulin (HUMULIN NOVOLIN)
growth factor-1, fibronectin, and retinol-binding
protein.
ü Urinary creatine and methylhistidine levels can
be used to gauge the degree of muscle wasting.
ü Because protein catabolism slows, urinary
urea level also decreases. These findings rarely affect
treatment.
Table 3. Values Commonly Used to Grade the Severity of
Protein-Energy Malnutrition
Measurement:
Ø Normal ---------------------- 90–110 (%)
Ø Mild Malnutrition------------85–90 (%)
Ø Moderate Malnutrition ----75–85 (%)
Ø Severe Malnutrition -------<75 (%)
Body mass index
Normal ------------------------ 19–24*
Mild Malnutrition------------18–18.9
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Moderate Malnutrition ----16–17.9 urinalysis,
Severe Malnutrition ------- < 16 urine culture,
Serum albumin (g/dL) blood cultures,
Normal-----------3.5–5.0 tuberculin testing, and
Mild---------------3.1–3.4 a chest x-ray are used to diagnose occult
Moderate--------2.4–3.0 infections because people with PEM may
Severe---------< 2.4 have a muted response to infections.
Serum transferrin (mg/dL) PREVENTION AND TREATMENT
Normal-----------220–400 Ø Worldwide, the most important preventive
Mild---------------201–219 strategy is to reduce poverty and improve
Moderate--------150–200 nutritional education and public health
Severe-----------< 150 measures.
Total lymphocyte count (per mm3) Ø Mild or moderate PEM, including brief
Normal--------------2000–3500 starvation, can be treated by providing a
Mild------------------1501–1999 balanced diet, preferably orally.
Moderate-----------800–1500
Ø Liquid oral food supplements (usually lactose-
Severe--------------< 800
free) can be used when solid food cannot be
Delayed hypersensitivity index†
adequately ingested.
Normal---------2
Ø Diarrhea often complicates oral feeding
Mild-------------2
because starvation makes the GI tract more
Moderate------1
likely to move bacteria into Peyer's patches,
Severe---------0
facilitating infectious diarrhea. If diarrhea
persists (suggesting lactose intolerance),
In the elderly,
yogurt-based rather than milk-based formulas
üBMI < 21 may increase mortality risk.
are given because people with lactose
ü †Delayed hypersensitivity index quantitates the intolerance can tolerate yogurt.
amount of induration elicited by skin testing using a Patients should also be given a multivitamin
common antigen, such as those derived from Candida supplement
sp or Trichophyton sp.
ü Induration
• Severe PEM or prolonged starvation requires
grade 0 = < 0.5 cm, treatment in a hospital with a controlled diet.
grade 1 = 0.5–0.9 cm, üThe first priority is to correct fluid and electrolyte
grade 2 = ≥ 1.0 cm. abnormalities (see Fluid and Electrolyte Metabolism)
Other laboratory tests can detect associated and treat infections.
abnormalities that may require treatment. ü Next is to supply macronutrients orally or, if
üSerum electrolytes, necessary, through a feeding tube, a nasogastric tube
ü BUN, (usually), or a gastronomy (G) tube.
ü glucose, and ü Parenteral nutrition is indicated if malabsorption is
severe (see Nutritional Support: Total Parenteral
ü possibly levels of Ca,
Nutrition (TPN)).
ü Mg,
ü Other treatments may be needed to correct
ü phosphate,
specific deficiencies, which may become evident as
ü and Na should be measured. weight increases.
Ø Levels of blood glucose and electrolytes ü To avoid deficiencies, patients should continue to
(especially K, phosphate, Ca, and Mg and take micronutrients at about twice the recommended
occasionally Na) are usually low. daily allowance (RDA) until recovery is complete.
Ø BUN is often low unless renal failure is IN CHILDREN:
present. • Underlying disorders should be treated.
Ø Metabolic acidosis may be present.
ü For children with diarrhea, feeding may be delayed
Ø CBC is usually obtained; normocytic anemia for 24 to 48 h to avoid making the diarrhea worse.
(usually due to protein deficiency) or
Ÿ Feedings are given often (6 to 12 times/day) but,
microcytic anemia (due to simultaneous iron
to avoid overwhelming the limited intestinal absorptive
deficiency) is usually present.
capacity, are limited to small amounts (< 100 mL).
üStool cultures should be obtained and checked
Ÿ During the first week, milk-based formulas with
for ova and parasites if diarrhea is severe or does
supplements added are usually given in progressively
not resolve with treatment.
increasing amounts;
üSometimes:

Ÿ after a week, the full amounts of 175 kcal/kg and
4 g of protein/kg can be given.
Ÿ Twice the RDA of micronutrients should be given,
using commercial multivitamin supplements.
Ÿ After 4 wk, the formula can be replaced with
whole milk plus cod liver oil and solid foods, including
eggs, fruit, meats, and yeast.
• Energy distribution among macronutrients should
be:
ü about 16% protein,
ü 50% fat, and
ü 34% carbohydrate.
ü An example is
Ÿ a combination of powdered cow's skimmed milk
(110 g), sucrose (100 g), vegetable oil (70 g), and
water (900 mL).
Ÿ Many other formulas (eg, whole [full-fat] fresh
milk plus corn oil and maltodextrin) can be used.
ŸMilk powders used in formulas are diluted with
water.
Usually, supplements should be added to formulas:
- Mg 0.4 mEq/kg/day IM is given for 7 days;
- B-complex vitamins at twice the RDA are given
parenterally for the first 3 days, usually with
vitamin A,
- phosphorus, zinc, manganese, copper, iodine,
fluoride, molybdenum, and selenium
SELSUN
(More in Mosby's Drug Consult)
Ÿ Because absorption of oral iron is poor in children
with PEM, oral or IM iron supplementation may be
necessary.
Ÿ Parents are taught about nutritional requirements
IN ADULTS:
üDisorders associated with PEM should be treated.
üFor example, if AIDS or cancer results in excess
cytokine production, megestrol acetate or
medroxyprogesterone may improve food intake.
üHowever, because these drugs dramatically
decrease testosterone Trade Names DELATESTRYL
in men (possibly causing muscle loss), testosterone
DELATESTRYL should be replaced.
ü Because these drugs can cause adrenal
insufficiency, they should be used only short-term (< 3
mo).
üIn patients with functional limitations, home delivery
of meals and feeding assistance are key.
Ø An orexigenic drug, such as the cannabis extract
dronabinol ARINOL, should be given to patients
with anorexia when no cause is obvious or to
patients at the end of life when anorexia impairs
quality of life.
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Anabolic steroids have positive effects (eg, increase
lean body mass, possibly improve function) in patients
with cachexia due to renal failure and possibly in
elderly patients
Correction of PEM in adults
ügenerally resembles that in children.
ü For most adults, feeding does not need to be
delayed;
ü small volumes are given often.
ü A commercial formula for oral feeding can be
used.
ü Nutrient supply should be given at a rate of 60
kcal/kg and 1.2 to 2 g of protein/kg.
ü If liquid oral supplements are used with solid food,
they should be given at least 1 h before meals so
that the amount of food eaten at the meal is not
reduced
ü Treatment of institutionalized elderly patients
with PEM requires multiple interventions,
ü including environmental measures (eg, making the
dining area more attractive);
ü feeding assistance;
ü changes in diet (eg, use of food enhancers and
caloric supplements between meals);
ü treatment of depression and other underlying
disorders;
ü and the use of orexigenics, anabolic steroids, or
both.
ü The long-term use of gastrostomy tube feeding is
essential for patients with severe dysphagia; its use in
patients with dementia is controversial
ü Increasing evidence supports the avoidance of
unpalatable therapeutic diets (eg, low salt, diabetic,
low cholesterol) in institutionalized patients because
these diets decrease food intake and may cause
severe PEM.
Complications of treatment:
Treatment of PEM can cause complications (refeeding
syndrome), including:
ü fluid overload,
ü electrolyte deficits,
ü hyperglycemia,
ü cardiac arrhythmias, and
ü diarrhea.
Ÿ Diarrhea is usually mild and resolves;
Ÿ however, diarrhea in patients with severe PEM
occasionally causes severe dehydration or death.
Ÿ Causes of diarrhea (eg, sorbitol used in elixir tube
feedings, Ÿ Clostridium difficile if the patient has
received an antibiotic) may be correctable.
Ÿ Osmotic diarrhea due to excess calories is rare in
adults and should be considered only when other
causes have been excluded.
üBecause PEM can impair cardiac and renal function,
hydration can cause intravascular volume overload.
ü Treatment decreases extracellular K and Mg.
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üDepletion of K or Mg may cause arrhythmias. •Very young children may develop mild mental
ü Carbohydrate metabolism that occurs during treatment retardation, which may persist until at least
stimulates insulin) release, which drives phosphate into school age.
cells. • Permanent cognitive impairment may occur,
Ø caused by a prolonged QT interval. depending on the duration, severity, and age
Ø Hypophosphatemia can cause muscle weakness, at onset of PEM.
paresthesias, seizures, coma, and arrhythmias. Key Recommendations for the General Population
With parenteral feeding, phosphate levels should
be measured regularly. ADEQUATE NUTRIENTS WITHIN CALORIE NEEDS
ü During treatment, endogenous insulin • Consume a variety of nutrient-dense foods
(HUMULIN NOVOLIN More in Mosby's Drug Consult) and beverages within and among the basic
may become ineffective, leading to hyperglycemia. food groups while choosing foods that limit the
ü Dehydration and hyperosmolarity can result. intake of saturated and trans fats, cholesterol,
üFatal ventricular arrhythmias can develop, possibly added sugars, salt, and alcohol.
• Meet recommended intakes within energy
PROGNOSIS: needs by adopting a balanced eating pattern,
• In children, mortality varies from 5 to 40%. such as the U.S. Department of Agriculture
• Mortality rates are lower in children with (USDA) Food Guide or the Dietary
milder PEM and those given intensive care. Approaches to Stop Hypertension (DASH)
• Death in the first days of treatment is usually Eating Plan.
due to electrolyte deficits, sepsis,
hypothermia, or heart failure.
• Impaired consciousness, jaundice, petechiae,
hyponatremia, and persistent diarrhea are
ominous signs.
• Resolution of apathy, edema, and anorexia
are favorable signs.
• Recovery is more rapid in kwashiorkor than in
marasmus.
• Long-term effects of PEM in children are not
fully documented.
• Some children develop chronic malabsorption
and pancreatic insufficiency.
• Very young children may develop mild mental
retardation, which may persist until at least
school age.
• Permanent cognitive impairment may occur,
depending on the duration, severity, and age
at onset of PEM.
• In adults, PEM can result in morbidity and
mortality (eg, progressive weight loss
increases mortality rate by 10% for elderly Basic of a healthy diet
people in nursing homes). 1. Balance- a diet consisting of Carbohydrate at 50-
• Except when organ failure occurs, treatment 60%, Protein at 10-15% maximum of 20% and
is uniformly successful. Fats at 20- 30% of total calories.
• In elderly patients, PEM increases the risk of 2. Moderation- Dietitian help clients learn to plan
morbidity and mortality due to surgery, food portion sizes appropriately.
infections, or another disorder. - involves learning the distinct difference between
• Recovery is more rapid in kwashiorkor than in hunger satisfaction and fullness.
marasmus. 3. Variation- All healthy diets involve the inclusion of
• Long-term effects of PEM in children are not several food-types, to obtain required amount of
fully documented. essential nutrients. Helps avoid food-boredom.
• Some children develop chronic malabsorption
and pancreatic insufficiency.
* Source: WholeFitness.com
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Top 10 power foods: National Health Objectives by 2004

1. Berries Goals:
2. Citrus Ø Prevalence rate of Protein-Energy
3. Vegetables malnutrition is reduced
4. Whole grains Ø Vitamin A deficiency is eliminated as a
5. Salmon public health problem
6. Legumes Ø Prevalence rate of iron deficiency anemia
7. Nuts and seeds is reduced
8. Lean proteins Ø Iodine Deficiency Disorders is eliminated
9. Tea as a public health problem
10. Olive oil ØPrevalence rate of overweight among preschoolers and
prevalence rate of obesity among adults is reduced
DOH Comprehensive Nutrition Program
General Objective: Health Status Objectives
Ø Reduction of morbidity and mortality rates due to 1. Reduce the prevalence rate of protein-energy
avitaminosis and other nutritional deficiencies. malnutrition
Program Strategies: Special Target 1993 Baseline 2004 Targets
Ø Standard Nutrition Intervention Program Population FNRI
1. Food and Micronutrient Supplementation Neonates 4.9% 3.5%
Ÿ Cereal – legume blend (0-28 days old)
Ÿ BP5 Compact food Infants (0-24 7.2% 6.25%
Regular supplementation during consultation months old)
Universal Supplementation: ASAP Preschoolers (25- 10.9% 9.0 %
Ø Vitamin A capsule to 12 to 59 months old 59 months
Ø Iodine capsule to 15 to 40 years old female School age
Ø Iron tabs to pregnant women children (7-14
2. Food Fortification years old)
Ø National Salt Iodization Program a. Stunting 5.5 % 4.5 %
Ø Salt iodization Bill ( Asin Law ) R.A. 8172 b. Wasting 6.6% 4.6 %
Ø Fortification of Value Rice c. Moderately 7.4% 5.6%
Ø Iron fortified Rice Project underweight
Ø Flour Fortification with Vitamin A Women and
Ø Sugar Fortification with Vitamin A mothers
a.Pregnant 21.3% 20%
Food Fortification: b. Lactating 12.8% 11.0%
• Educational approaches:
-encourage breastfeeding diet 2. Reduce the prevalence rate of Vitamin A Deficiency
• WHO Guidelines: Special Target 1993 Baseline 2004 Targets
-measles Population (FNRI)
-persistent, chronic diarrhea Preschoolers 0.4% 0%
-respiratory tract infection (6 mths-6 yrs old)
-severe PEM Women and
-intestinal parasitism mothers
-pregnant female-Vit.A not 10,000 units per day,200,000 a. Pregnant 0.5% 0.2%
I.U.within 2 months after delivery b. Lactating 1.0% 0.3%
-food products contain at least 1/3 of RDA
3. Reduce the prevalence rate of Iron Deficiency
B. Support Programs Anemia
1. Community Assessment Special Target 1993 Baseline 2004 Targets
Ø Operation Timbang (OPT) Population FNRI
Ø IDD/VAD Prevalence Surveys Neonates (0-28 8.7% 6.0%
2. Training / Human Resource Development days old)
3. Operations Research Infants (0-24 49.2% 38.1%
4. Monitoring and Evaluation months old)
5. Planning Preschoolers (25- 26.7% 20.0 %
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59 months) 7. Increase the percentage of individuals consuming green

School age 30.8% 20.4% leafy and yellow vegetables to 100%.( Baseline: 87.6% in
children (7-14 1995 , Exploratory Survey on Healthy Dep”t )
yrs) 8. Increase the percentage of the individuals consuming
Women and foods rich in protein, vitamin A, iron, and iodine (Baseline
mothers data is established in 2000)
a.Pregnant 43.6% 33.7% 9.Achieve 100% universal salt iodization.( Baseline: 10%
b. Lactating 43.0% 33.3 in 1998,NS Report)
Older Persons 45.6% 38.O% 10.Increase the level of awareness on healthy diet and
(60 yrs & older) maintenance of desirable body weight (Baseline is
established in 2000)
4. Reduce the prevalence rate of iodine deficiency 11.Increase the proportion of overweight and obese
disorders (IDD) seeking dietary counselling and practicing prescribed diet
Special Target 1993 Baseline 2004 Targets restriction. (Baseline data is established in 2000)
Population FNRI 12.Increase the level of awareness on food safety.
School age children (Baseline data is established in 2000)
(7-14 yrs)
0.6% 20.4% SERVICE AND PROTECTION OBJECTIVES
A. Males
B. Females 4.5%
1. Institutionalize “nutri-clinic” as part of health
Older Women and facilities. (Baseline data is established in 2000)
mothers 2. Increase the proportion of moderately and
a.Pregnant 49.9% 38.O% severely underweight children without medical
b. Lactating 42.2 32% complications rehabilitated at mothercraft centers
or weighing posts to 15%.(Baseline 10.7% in
5. Reduce the prevalence rate of overweight and 1997, FHSIS)
obese among the pop’n 3. Increase the proportion of severely underweight
Special Target Population 1993 2004 children with medical complications referred to
Baseline Targets hospitals or nutri wards to 25%)
FNRI 4. Increase the coverage of iron supplementation
Preschoolers (0-6 yrs old) 6.5% 5.3%
Special target 1998 baseline 2004 target
Adults (20 years old and pop’n (NS report)
over) Infants (6-11 Baseline data is established in 2000
A. Males 14.3% 12.3% months)
18.6% 16.6% Pregnant women 64% 74%
B. Females 5. Increase the coverage of Vitamin A
supplementation among 12- to 59-month old children to
Risk Reduction Objectives: 100 %.
1. Increase the proportion of infants exclusively breastfed (Baseline :90% in 1998) FETP Survey
up to six months of age to 30%.(Baseline:20% in
1988,NDHS) Food Fortification Project Strategic Plan of the DOH
2. Increase the proportion of infants given complementary
foods at about six months of age to 30% (Baseline: 60.9% -Micronutrient deficiency is one of the major health
in 1998, NDHS) problems in the Philippines particularly vitamin A, iron, and
3. Increase the proportion of mothers or caregivers taking iodine deficiencies. To address this problem the
their children to weighing posts, mothercraft centers, or Philippines has embarked on a three-pronged strategy
health facilities (Baseline data is established in 2000) of
4. Increase the percentage of individuals practicing üsupplementation,
healthy diet to 50 % ( Baseline:30.7% in 1995, Exploratory ü nutrition education, and
Survey on Healthy Diet) ü food fortification.
5. Reduce the percentage of individuals eating junk foods
• Based on studies, food fortification is the most
to 50% (Baseline:81.3% in 1995, Exploratory Survey on
cost effective and sustainable strategy to address
Healthy Diet)
micronutrient supplementation.
6. Reduce the percentage of individuals eating fast foods
to 50% (Baseline: 79.3% in 1995 Exploratory Survey on • This 5-year Food Fortification Strategic Plan
Healthy Diet.) 2000-2004 in response for the need to fast track

food fortification of staples and processed foods
was developed by:
-The United Nations Children’s Fund (UNICEF)
- the United States Agency for International
Development (USAID) and
- the Asian Development Bank (ADB)
Weaknesses in the present system :
Ø -lack of gov’t understanding on the needs of the
food industry for fortification
Ø -lack of clear policy due to the absence of
empirical and scientific evidences
Ø -lack of research support
Ø -lack of monitoring system and
Ø -weak advocacy and promotion of the project
Ø Current program for micronutrient
supplementation seen as a medium term
solution to the problem involves:
- twice yearly vitamin supplementation of pre-school
children through the Garantisadong Pambata
- Vitamin A supplementation of VAD cases
postpartum women and risk cases for VAD , ie:
measles, chronic diarrhea, acute respiratory infections and
malnutrition,iodine supplementation to identified cases of
goiter in endemic areas and women ages 15 to 40 years
and iron supplementation of infants, pregnant and
lactating women
Ø Issues related to the micronutrient
supplementation program:
- lack of supplements
- lack of efficient delivery
- high cost to the government and
-sustainability
Ø Goal of the 5-year plan:
- to make widely available vitamin A, iron, and iodine
fortified foods that would contribute to an increase in the
micronutrient intake by at least 50% of the RDA of the
vulnerable groups (preschool children and women of
reproductive age group) by 2004.
The plan is to continue with the projects currently
implemented as follows:
-fortification of salt with iodine
-hard flour with Vit A and iron
-NFA rice with iron
-sugar with Vitamin A
-edible oil with Vitamin A and
-processed foods with Sangkap Pinoy Seal particularly
condiments with iron
Ø Food Fortification Management Team is managed
by:
- members from the Dep’t of Health
- a team of consultants which would report
to the DOH
Ø The 4 intervention activities of the Management
Team:
- technology and internal quality assurance
Subject:
Topic:
Page 10 of 2
- promotion and advocacy
- legislation, policy and guidelines development
- research, surveillance and external
monitoring/quality assurance
Dietary diversification through food production :
ü takes time since this involves behavioral change
and depends on the economic status of an individual
or a country.
Ø In the Philippines there is no integrated plan for
nutrition education activities
-Nutrition education activities are being implemented by
different government agencies such as the
üDOH,
üNational Nutrition Council ,
ü FNRI,and
ü various non-governmental organizations such as
Nutrition Council of the Philippines (NCP)
Helen Keller International and ( HKI )
Barangay Integrated Development Assistance for
Nutrition Implementation ( BIDANI)
Ø Weaknesses in the present system :
-lack of gov’t understanding on the needs of the food
industry for fortification
-lack of clear policy due to the absence of empirical and
scientific evidences
-lack of research support
-lack of monitoring system and
-weak advocacy and promotion of the project
Operation Timbang
Ø Objectives of Operation Timbang
Ø
Ø
General:
-To generate data for nutrition assessment, planning,
management and evaluation of local nutrition programs
Specific:
1. to locate families with preschoolers whose weight is
below or above normal
2. To identify and quantify preschoolers with below and
above the normal weights needing immediate assistance
3. To locate families with preschoolers with cleft palate or
harelip
4. To detect growth faltering among infants and
preschoolers as early as possible
5. To encourage parents or guardians or caregivers to
have their preschoolers weighed regularly
6. To determine priority areas and individuals for local
program implementation (e.g. food and/or micronutrient
supplementation, livelihood program and others
7. To provide appropriate health and nutrition services to
preschoolers whose weights fall below normal and

8. To assess the effectiveness of the local nutrition
program
Uses of the OPT:
• Data gathered by the OPT is used for nutrition
assessment and local planning evaluation and
education.
• Through OPT the magnitude of PEM,
malnutrition and the incidence of cleft palate
or harelip among preschoolers in the
bgy/municipality/city/ region can be estimated.
• The incidence of cleft palate could be
indicative of deficiencies in
Biotin,B6(pyridoxin)Vitamin A, folic acid and
zinc.
• At the barangay, preschoolers with weights
below normal and who belong to the poor
families can be identified and provided
immediate intervention.
• At the national level, nutritionally depressed
municipalities, cities, and provinces can be
identified for targetting and planning
purposes.
• As an evaluation tool results of OPT are used
to assess the:
-Impact of the interventions
-overall nutritional progress of the community and
-efficiency of the local nutrition program
Definition of Terms:
Nutrition
ü is the science of food and its relationship to health.
Essential Nutrients:
ü Nutrients that cannot be synthesized by the body and
thus must be derived from the diet are considered
essential.
üThey include vitamins, minerals, some amino acids,
and fatty acids.
They are needed by the body for one or more of these
functions: to provide heat and / or energy ; to build and
repair tissues ; and to regulate life processes. Although
nutrients are found chiefly in foods some can be
synthesized in the laboratory like vitamins and mineral
supplements or in the body through biosynthesis.
Nonessential Nutrients:
ü Nutrients that the body can synthesize from other
compounds, although they may also be derived from the
diet, are considered nonessential.
ü Micronutrient: an essential nutrient required by the
body in very small quantities recommended intakes are
milligrams or micrograms
• Fortification- the addition of nutrients to
processed foods /products at levels above the
Subject:
Topic:
Page 11 of 2
natural state as an approach to control
micronutrient deficiency, food fortification is
the addition of micronutrient deficient in the
diet to a food which is widely consumed by
specific risk groups to improve its nutritional
value.
• Sangkap Pinoy Seal Program- a strategy to
encourage manufacturers to fortify processed
food products with essential nutrients at
levels approved by the DOH. The
fundamental concept of the program is to
authorize manufacturers to use the DOH seal
of acceptance for processed foods after these
products passed a set of defined criteria. The
seal is a guide used by consumers in
selecting nutritious foods.
• RDA- recommended dietary allowance; levels
of nutrient intakes which are considered
adequate to maintain health and provide
reasonable levels of reserves in the body
tissues of nearly all healthy persons in the
population
• Staple food-basic food normally consumed by
the general population on a daily basis,e.g.
rice, flour, sugar, oil
Undernutrition
ØLack of nutrients can result in deficiency syndromes.
ükwashiorkor
üpellagra) or other disorders
Obesity and the Metabolic Syndrome: Obesity
üExcess intake of macronutrients
can lead to obesity.
Toxic:
üExcess intake of micronutrients can
be toxic.
Macronutrients:
üare required by the body in relatively large amounts
üMacronutrients constitute the bulk of the diet and
supply energy and many essential nutrients.
♥Carbohydrates,
♥ proteins (including essential amino
acids)
♥ fats (including essential fatty acids),
♥ macrominerals, and
♥ water are macronutrients.
Macronutrients (cont’d)
Carbohydrates, fats, and proteins are interchangeable
as sources of energy:
♥ fats yield 9 kcal/g (37.8 kJ/g);
♥ proteins and
♥ carbohydrates yield 4 kcal/g (16.8
kJ/g).
Micronutrients are needed in minute amounts.
Basic Nutritional Needs
 Subject:
Topic:
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The Minimum daily recommended allowances • Adults: calcium, potassium, fiber, magnesium,
o Calories - 2700 and vitamins A (as carotenoids), C, and E,
o Protein - 56 grams
• Children and adolescents: calcium,
o Calcium - 0.8 g
potassium, fiber, magnesium, and vitamin E,
o Iron - 10 mg
o Vit. A - 5000 IU • Specific population groups (see below):
o Thiamine - 1.4 mg vitamin B12, iron, folic acid, and vitamins E
and D.
o Vit C - 45 mg
o Riboflavin - 1.6 mg • At the same time, in general, Americans
 Niacin - 18 mg consume too many calories and too much
saturated and trans fats, cholesterol, added
A well nourished person… sugars, and salt.
Dietary Reference Intakes (DRIs): Recommended
Ø Possesses Abundant Vitality
Intakes for Individuals, Vitamins
Ø Bones are well formed
(Food and Nutrition Board, Institute of Medicine, National
Ø Muscles well developed and strong Academies)
Ø Contour of body is pleasing
Ø Body functions efficiently Life Vit Vit. Vit. Vit. Vit.
Stage A C D E K
Key Recommendations for Specific Population group
Groups Infants 0- 400 40 5 4.0 2.0
• People over age 50. Consume vitamin B12 in 6 months
its crystalline form (i.e., fortified foods or Children
supplements). 1-3 300 15 3+ 6 30
• Women of childbearing age who may become 4-8 400 25 5+ 7 37
pregnant. Eat foods high in heme-iron and/or Males
consume iron-rich plant foods or iron-fortified 9-13 600 45 0.9 0.9 12
foods with an enhancer of iron absorption, 14-18 900 75 1.0 1.0 16
such as vitamin C-rich foods. 19-30 900 90 1.1 1.1 16
31-50 900 90 1.1 1.1 16
• Women of childbearing age who may become 51-70 900 90 1.1 1.1 16
pregnant and those in the first trimester of >75 900 90 1.1 1.1 16
pregnancy. Consume adequate synthetic folic
acid daily (from fortified foods or supplements) Life Thiami Riboflav Niaci Vit Pantot Bioti
in addition to food forms of folate from a Stage ne in n B henic n
varied diet. group Acid
• Older adults, people with dark skin, and
people exposed to insufficient ultraviolet band Infant 0.2 0.3 2.0 0.3 1.7 0.5
radiation (i.e., sunlight). Consume extra s 0-6
vitamin D from vitamin D-fortified foods and/or month
supplements. s
Childr
KEY RECOMMENDATIONS en
• Consume a variety of nutrient-dense foods 1-3 0.5 0.5 6 0.5 150 .9
and beverages within and among the basic 4-8 0.6 0.6 8 0.6 200 1.2
food groups while choosing foods that limit the
intake of saturated and trans fats, cholesterol,
added sugars, salt, and alcohol.
• Meet recommended intakes within energy
needs by adopting a balanced eating pattern,
such as the USDA Food Guide or the DASH
Eating Plan.
• Based on dietary intake data or evidence of
public health problems, intake levels of the
following nutrients may be of concern for:

Obesity: Understanding Adult Obesity
- The Rising Rate of Childhood Obesity is Alarming
- 30% of children are overweight or at risk for
overweight
WEIGHT MANAGEMENT
• To maintain body weight in a healthy range,
balance calories from foods and beverages
with calories expended.
• To prevent gradual weight gain over time,
make small decreases in food and beverage
calories and increase physical activity.
NUTRITIONAL GUIDELINES FOR FILIPINOS–
REVISED ED. 2000
1. Eat a variety of foods everyday.
2. Breastfeed infants exclusively from birth to 4-6
months, then give appropriate foods while
continuing breastfeeding.
3. Maintain children’s normal growth through proper
diet and monitor their growth regularly.
4. Consume fish, lean meat, poultry or dried beans.
5. Eat more vegetables, fruits, and root crops.
6. Eat foods cooked in edible/cooking oil daily.
7. Consume milk, milk prod. or other calcium rich
foods such as small fish and dark green leafy
vegetables everyday.
8. Use iodized salt, but avoid excessive intake of
salty foods.
9. Eat clean and safe foods.
10. For a healthy lifestyle and good nutrition, exercise
regularly, do not smoke, and avoid drinking
alcoholic beverages.
PHYSICAL ACTIVITY
Subject:
Topic:
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• Engage in regular physical activity and reduce
sedentary activities to promote health,
psychological well-being, and a healthy body
weight.
• To reduce the risk of chronic disease in
adulthood: Engage in at least 30 minutes of
moderate-intensity physical activity, above
usual activity, at work or home on most days
of the week.
• For most people, greater health benefits can
be obtained by engaging in physical activity of
more vigorous intensity or longer duration.
• To help manage body weight and prevent
gradual, unhealthy body weight gain in
adulthood: Engage in approximately 60
minutes of moderate- to vigorous-intensity
activity on most days of the week while not
exceeding caloric intake requirements.
• To sustain weight loss in adulthood:
Participate in at least 60 to 90 minutes of daily
moderate-intensity physical activity while not
exceeding caloric intake requirements. Some
people may need to consult with a healthcare
provider before participating in this level of
activity.
• Achieve physical fitness by including
cardiovascular conditioning, stretching
exercises for flexibility, and resistance
exercises or calisthenics for muscle strength
and endurance.
Weight Control Information Network
• What is Obesity
• How is Obesity Measured
• Body Mass Index
• Body Fat Distribution
• Causes of Obesity
• Consequences of Obesity
• Who should lose weight
• How is Obesity treated
What is Obesity?
• …”to be very overweight”…
• OVERWEIGHT - Excess amount of body
weight (muscles, bone, fat, water)
• OBESITY – Excess amount of body fat
Fats
• Energy storage
• Heat insulation
• Shock absorption
• Women more body fat
Measuring Body Fat
 Subject:
Topic:
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• Underwater measurement
• Dual energy XRay Absorptiometry (DEXA)
• FAT Thickness
• Bio-Cutaneous Meter

Body Mass Index

• Formulae using patient’s weight and height
• BMI = weight (kg) / height (m) 2
 BMI = 25 – 29.9 ( overweight ) Psychological and Social Effects:
• = >30 ( obese) • Emotional suffering
Body Fat Distribution • Prejudice / discrimination
• Women – collect fats in hips, buttocks • Feelings of rejection / shame / depression
• Men – collect fats in bellies
• Waist measurement Other health problems…
 women > 35 inches • Gallbladder disease and gallstones
 men > 40 inches • Liver disease
• Osteoarthritis
Causes of Obesity • Gout
• Pulmonary problems
Genetic factors:
• Reproductive problems
Ø Environmental Factors
• Lifestyle behaviors
Consequences of Obesity
• Physical activity Health Risks
Ø Psychological Factors • Type 2 Diabetes
• Response to negative emotions • Heart Disease
• Binge eating disorders • Hypertension
o Depression / Low self-esteem • Stroke
• Cancer (colon, rectum, prostate, gallbladder,
Other causes… breast, uterus ,cervix, ovaries)
Ø Medical illnesses
• Hypothyroidism Who should lose weight?
• Cushing’s syndrome *BMI – 25-29.9 – prevention of additional
• Depression weight gain recommended
• Neurological problems Ø Family History of Chronic Diseases
Ø Drugs • Diabetes , Heart Disease
• Steroids Ø Pre-existing Medical Condition
• Antidepressants • Hypertension
• High Cholesterol
Consequences of Obesity • High Sugar level
Health Risks Ø “ Apple” shape
• Type 2 Diabetes
• Heart Disease Treatment
• Hypertension Ø Depends on:
• Stroke • Level of Obesity
• Cancer (colon, rectum, prostate, gallbladder, • Overall Health Condition
breast, uterus ,cervix, ovaries) • Motivation to Lose weight
Ø Modes:
• Diet
• Exercise
• Behavior Modification
• Weight losing drugs
• Surgery
Treatment: DIET
 Subject:
Topic:
Page 15 of 2
-Limit intake of food rich in cholesterol and
saturated fats Important numbers to remember:
- Eat more fruits and vegetables Blood Pressure
- Reading labels is helpful. Choose food with • Increase in blood pressure à increases
low fat content.
heart workloadà heart enlarges à heart
- Use cooking methods that require little or no
weakens
oil.
• Salt restriction
-Eat fish more often than meat or poultry
-Limit intake of egg yolks to 3-4 times a week • Caffeine reduction
-Eat more of dried beans, peas and legumes • Lifestyle changes - exercise
-Eat more cereals and grains

Treatment: EXERCISE
-30-60 minutes of aerobic exercise 3-4 times a Cholesterol
week • Risk of heart disease increases as
-Increase physical activity at home and at work Cholesterol increases
Treatment: DRUGS • Good cholesterol – HDL > 35 mg/dl
• Bad cholesterol – LDL < 130 mg/dl
Top 10 Benefits of Being Active • Low fat, low cholesterol diet
1. Improve blood glucose management. Activity
• Fruits and vegetables
makes your body more sensitive to the insulin you
make. Activity also burns glucose (calories). Both • 20-30 mins. Exercise - 3 days a week
actions lower blood glucose.]
2. Lower blood pressure. Activity helps your heart Supplements to Boost your Health
pump stronger and slower. Vitamin B12 – needs stomach acid to be absorbed
** supplement form- No Acid needed
3. Improve blood fats. Exercise can raise good Symptoms:
cholesterol (HDL) and lower bad cholesterol (LDL)
• Anemia
and triglycerides. These changes are heart
healthy. • Blood cell disorders
4. Take less insulin or diabetes pills. Activity can • Neurological disorders
lower blood glucose and weight. Both of these • Changes in gait
may lower how much insulin or diabetes pills you 2.4 microgr/day
need to take. Folate ( Folic acid)
5. Lose weight and keep it off. Activity burns calories. • B Vitamin that reduces levels of
If you burn enough calories, you'll trim a few HomoCysteine
pounds. Stay active and you'll keep the weight off. • Found in dark green, yellow and orange
6. Lower risk for other health problems. Reduce fruits and vegetables
your risk of a heart attack or stroke, some • Beans, nuts, fortified grain products –
cancers, and bone loss pasta and flour
7. .Gain more energy and sleep better. You'll get
• Spinach, orange juice and lentils
better sleep in less time and have more energy,
Calcium and Vitamin D
too.
o 1,200 microgm/day
8. Relieve stress. Work out or walk off daily stress.
9. Build stronger bones and muscles. Weight- o Calcium carbonate – citrate
bearing activities, such as walking, make bones o Skin – main producer of Vitamin D
stronger. Strength-training activities, such as lifting o Elderly people – 10 – 15 mg/ day
light weights (or even cans of beans), make
muscles strong.
10. Be more flexible. Move easier when you are “…DIETARY SUPPLEMENTS ARE NOT DIETARY
active. SUBSTITUTES…”

Nutrition and Disease Prevention

• Lowers Heart Disease
• Lowers High Blood Pressure
• Lowers Cancer
• Lowers Bone loss
• Increases Immune System