PUBLIC HEALTH NUTRITION

Dr. TIRTA PRAWITA SARI, MSc

Definitions
Clinical nutrition: more in treatment, less prevention and
promotion, personal treatment
Public health nutrition focuses on the promotion of good
health (the maintenance of wellbeing or wellness, quality
of life) through nutrition and the primary (and secondary)
prevention of nutrition- related illness in the population
(nutrition society)

UNICEF s CONCEPTUAL FRAMEWORK OF MALNUTRITION

Malnutrition and death
Inadequate
dietary intake

Inadequate
access to food

Disease

Inadequate
care for mothers
n children

Immediate
causes

Insufficient health
services n unhealthy
environment

Inadequate education
Formal n nonformal
institutions

Underlying
causes

Political n ideological superstructure

Economic structure
Potential resources

Basic
causes

The Triple A Cycle

1. Assessment: situation

assessment

analysis

2.
3.
4.
5.

action
6.

analysis; identify problems and

select opportunity for
improvement
Define the problem
operationally
Identify who needs to work on
the problem
Analyze and study the problem
to identify major causes
Develop solutions and action
for quality improvement
Implement and evaluate
quality improvement effort

The public health nutrition cycle

1.Identintify key nutritionrelated problem

2. Set goal
7. Evaluate
program

3. Define objectives
for goal

6. Implement
program

4. Create quantitative
targets

5. Develop program

Major nutritional problems in Indonesia

Under-nutrition
Vitamin A deficiency
Iodine deficiency disorder
Iron deficiency anemia

Under-nutrition

Classification of under-nutrition by
based on NCHS reference (WHO, 1995)
Indicator

Z score

Classification of
under-nutrition

Weight for age Z score

< - 2 SD

Underweight

Height for age Z score

< - 2 SD

Stunting

Weight for height Z score

< - 2 SD

Wasting

Mechanism of reduced nutritional status

Decreased nutrient intake
Decreased nutrient absorption
Decreased nutrient utilization
Increased nutrient losses
Increased nutrient requirements

Nutrition and immunity in under-nutrition

Weight loss, growth
faltering, lowered
immunity, mucosal
damage

Disease; incidence,
severity, duration

Inadequate dietary
intake
Appetite loss,
nutrient loss,
malabsorption,
altered metabolism

Public health consequences of under-nutrition

Susceptibility to mortality
Susceptibility to acute morbidity
Decreased cognitive development
Decreased economic productivity
Susceptibility to chronic diseases in later life

Malnutrition and death

Inadequate
dietary intake

Inadequate
access to food

Disease

Inadequate
care for mothers
n children

Immediate
causes

Insufficient health
services n unhealthy
environment

Inadequate education
Formal n nonformal
institutions

Underlying
causes

Political n ideological superstructure

Economic structure
Potential resources

Basic
causes

General guidelines to assist in decisions to implement

nutrition program
Malnutrition rate 20%
or

GENERAL
RATION < 2100
Kcal/pers/day

Malnutrition rate 15-19%

+ aggravating factors

BLANKET supplementary
feeding, supplementary
feeding, THERAPEUTIC
feeding program

Malnutrition rate 10-15%

ALERT

or

Always improve
general rations

SERIOUS

Malnutrition rate 5-9% +

aggravating factors
Malnutrition rate < 10%
with no aggravating
factors

Taken from Care International

TARGETED
supplementary feeding,
THERAPEUTIC feeding
program
ACCEPTABLE
No need for population
level interventions
(individual attention for
malnourished

Related Terms

Aggravating factors:
Mortality: crude mortality rate > 1/10.000/day
Inadequate general food rations
Epidemic of measles, shigella or other important communicable
diseases
Severe cold and inadequate shelters
Blanket supplementary feeding: provides a quality or energy
supplement in addition to the normal ration which is distributed to all
members or identified vulnerable groups to reduce risk
Targeted supplementary feeding provides energy or quality dietary
supplements and basic health screening to those that are already
moderately malnourished to prevent them from becoming severely
malnourished and improve their nutritional status (curative)
Therapeutic feeding provides a carefully balanced and intensively
managed dietary regimen with intensive medical attention, to
rehabilitate the severely malnourished (curative) and reduce excess
mortality

Prevention

Growth monitoring and nutrition education

PREVALENCE OF MALNUTRITION AMONG UNDER-FIVES

BY PROVINCE, SUSENAS 1999
11
12
64

14
13

61
15

<15%
15-19.9%
>=20%

71

17

72

62
16

63
18

81

73
74

82

31
32

33
34

Source : Ministry of health, 1999

35

51

52
53

88

PREVALENCE OF SEVERLY MALNOURISHED

AMONG UNDER-FIVES BY PROVINCE, SUSENAS 1999
11
12
64

14
13

71

61
15
17

72

62
16

63
18

73
74

<5%

31

5-9.9%

32

33

>=10%

Source : Ministry of health, 1999

34

35

51

81
82

52
53

89

The prevalence of underweight among pre-school children, 2003

Micronutrients deficiency

Selected micronutrient deficiencies, consequences,

and strategies (1)
Micronutrient Clinical
manifestatio
ns of
deficiency

Public health Effective

magnitude of interventions
the problem

Vitamin A

100 million
children,
contributory
factor in 3
million
childhood
deaths
annually

Damage to
cornea and
retina leading
to partial
blindness,
increased
severity of
diarrhea and
malaria

Single dose
supplementati
on
administered
with
vaccination

Selected micronutrient deficiencies, consequences,

and strategies (2)
Micronutrient

Clinical
Public health
manifestations magnitude of
of deficiency
the problem

Effective
interventions

Iron

Anemia, poor
cognitive
development,
increased
susceptibility to
infection

2 billion people
worldwide,
mostly women
and children

Fortification,
administration of
supplements
and
antihookworm
treatment

Iodine

Poor cognitive
development

43 million
worldwide,
primarily in
areas where
soils are iodine
poor

Salt iodization

Vitamin A deficiency

Criteria for assessing the public health significance of

xerophtalmia and vitamin A deficiency, based on the
prevalence among children aged less than 6 years old
in the community
Criterion

Minimum
prevalence (%)

Clinical (primary)
Night blindness (XN)

> 1.0

Bitots spot (X1B)

> 0.5

Corneal xerosis/ulceration/keratomalacia
(X2,X3A,X3B)

> 0.01

Xerophtalmia-related corneal scar (XS)

> 0.05

Biochemical (supportive)
Serum retinol (vitamin A) < 0.35 mol/l (<
10 g/dl

> 5.0

Summary schedule for high dose vitamin A

supplementation of postpartum women and
infant/children in vitamin A deficient areas
At
birth

Mother
Infant/child

6 weeks

10
weeks

14
weeks

9
months
(or any
time
between
6 and 11
months

12-59
months

100.000
IU

200.000
IU every
46
months

200.000 IU*
50.000
IU

50.000
IU

50.000
IU

* At delivery and another 200.000 IU during the safe infertile postpartum

period at least 24 h after the first dose

Different public health approaches to modifying

vitamin A intake used in the prevention and
control of vitamin A deficiency (1)
Food based
Dietary diversification
Home gardening
Nutrition education
Development of high carotenoid content varieties of staple foods
Fortification
Sugar
Flour
Margarine, edible oils
Noodles
Condensed milk and other dietary products
Condiments
Other food vehicles

Different public health approaches to modifying

vitamin A intake used in the prevention and control of
vitamin A deficiency (2)
Supplementation
National distribution to all preschool children
National immunization days and national micronutrient days through
health system centers, including maternal and child health program
With expanded program immunization
Postpartum supplementation
Life cycle distribution to adolescents and young women through
schools and factory
Complementary public interventions
Ecological, political, and socioeconomic interventions

Core indicators for assessing the progress of

vitamin A deficiency control program

Indicators

Prevalence goal

Functional indicators
Night blindness (children 24 71
months of age)

< 1%

Biochemical indicators
Serum retinol 0.70 mol/l or

< 5%

Breast milk retinol 1.05 mol/l or 8

g/g milk fat

< 10%

Iodine deficiency disorder

Classification of IDD

Diagnosis of iodine deficiency should be seen as a

group, community, or population diagnosis rather than an
assessment on the individual level
IDD status is interpreted through the summary data of
the group.
Indonesia: prevalence of goiter decreased from 27.9%
(1990) to 11.1% (2003)

Classification of Iodine status of a population

based on median urinary iodine concentration*
Iodine status

Median urinary iodine

concentration (g/l)

Severe Iodine deficiency

Moderate Iodine deficiency

<20
20-49

Mild Iodine deficiency

Ideal Iodine intake

50-99
100-200

More than adequate iodine

intake; may pose increased
risk of iodine-induced
hyperthyroidism

201-299

Excessive iodine intake

>300

*As consulted with WHO, UNICEF, and ICCIDD

Measurement of thyroid size

By palpation
Grade 0: no palpable or visible goiter
Grade 1: a mass in the neck that is consistent with
an enlarged thyroid that is palpable but not visible
when the neck is in the normal position, but moves
upwards in the neck as the subject swallows;
nodular alteration can occur even when the thyroid
is not visibly enlarged
Grade 2: a swelling in the neck that is visible when
the neck is in a normal position and is consistent
with an enlarged thyroid when the neck is palpated
By USG

Reference intake for iodine

(WHO/UNICEF/ICCIDD, 2001)
Category

Intake (g/day)

Under-fives, 0-59 months

90

School children, 6-12 years

120

Children > 12 years and adults

150

Pregnant and lactating women

200

Management of iodine deficiency

Strategies depend on:
The severity of IDD
The accessibility of the target population
The resources available,
Strategies:
Food-based approaches
Use of natural foods

Strategy to eliminate IDD

Use of iodized salt
Iodination of drinking water
Fortification of infant formulas
Fortification of other foods
Fortification of foods consumed by farm animals
Nutraceutical approaches
Use of iodized oil
Use of potassium iodine solution (30 mg every
month or 8 mg every 2 weeks)

Evaluation of IDD elimination program

Process indicators:
Coverage of iodized salt at household level in
representative sample of a community or population
(household salt with iodine concentration > 15
mg/kg, ideally the percentage should exceed 90%)
Outcome indicators:
Urinary iodine secretion
Thyroid size, TSH, and thyroglobulin
Cretinism
T4 and T3 levels.

Prevalensi Gondok Anak Sekolah di Indonesia 1998

Menurut Propinsi
11
12
64

14
13

61
15
17

Keterangan
< 5

16

63
18

81

73
74

82

31

32

33
34

20-29.9 %

11
12
13
14
15
16
17
18

72

62

5 - 19.9 %

> 30

71

35

51

52
53

Aceh
Sumatera Utara
Sumatera Barat
Riau
Jambi
Sumatera Seleatan
Bengkulu
Lampung

5.4%
6.7%
20.5%
1.1%
3.7%
7.3%
7.9%
11.9%

31
32
33
34
35
51
52
53
54

Jakarta
2.0%
Jawa Barat
4.5%
Jawa Tengah
4.4%
Yogyakarta
6.1%
Jawa Timur
1 6.3%
Bali
12.0%
Nusa Tenggara Barat 19.7%
Nusa Tenggara Timur 38.1%
Timor Timur
21.4%

61 Kalimatan Barat
2.3%
62 Kalimatan Tengah
8.1%
63 Kalimatan
Selatan
1.7%
64
Kalimatan Timur
3.1%
71 Sulawesi Utara
3.0%
72 Sulawesi Tengah
16.5%
73 Sulawesi Selatan
10.1%
74 Sulawesi Tenggara 24.9%

81 Maluku
82 Papua

33.3%
13.0%

90

Iron deficiency anemia

IDA is considered to be present in a population only when

the prevalence of Hb below the cutoff is greater than 5%
The evidence indicates that the prevalence of iron
deficiency is double that of IDA
Indonesia: the prevalence of IDA among pregnant women
decrease from 50.9% (1995) to 40% (2001), women aged
15 44 years 39.5% to 27.9%, whereas for under-fives
the prevalence increased from 40% to 48.1%, particularly
higher in children < 24 months (> 55%)

Hb and Ht cutoffs used to determine anemia*

Age or sex group

Hb below (g/dl)

Ht below (%)

11

33

11.5

34

Children 12-13 years

12

36

Non-pregnant women

12

36

Pregnant women

11

33

Men

13

39

Children 6 months to 5
years
Children 5-11 years

*Source: Indicators for assessing IDA and strategies for its prevention,
WHO/UNICEF/UNU

Stages of iron depletion

Stage I

Stage II

Stage III

Decrease
in iron stores

Biochemical
Indicators of low
Iron stores

IDA

Feritin

Transferrin saturation
Erythrocyte protoporphyrin

Hemoglobin

Factors influencing iron absorption

Type of food consume
Interaction between foods
Regulatory mechanisms in the intestinal
mucosa
Bioavailability
Amount of iron stores
Rate of production of RBC

Risk factor for anemia

Poor iron stores
Dietary inadequacy
Increased demands
Malabsorption and increased losses
Hemoglobinopathies
Drug and other factors

Schematic of integrated strategy for prevention and

control of iron deficiency
Assessment for iron deficiency and IDA
Balance and phase interventions as appropriate
Dietary
Change

Fortification
Of foods

Oral
Supplemention

Infection
control

Research
and
monitoring

Program implementation

Program linkage

FP
Reproductive
health

Breastfeeding
promotion

Expanded program
on immunization

Integrated
management of
childhood illness

Several key players in the development of

policy
Policy holders (usually government politicians)
Policy influencers (lobby groups representing vested
interests)
The public
The media
Key determinants of policy development
The social climate
Identifiable parties that influence policy
What interested parties will gain from the policy
The ability of those interested parties to make their
voices heard