Dasar-dasar gizi

masyarakat
Dr. joko wahyu wibowo MKes
The Natural history of disease in a
patient
Preclinical Phase Clinical Phase

(A) (P) (S) (M) (D) (T)

 A ; Biologic onset of disease

 P ; Pathologic evidence of disease if Sought
 S ; Signs and symptoms of disease
 M ; Medical care sought
 D ; Diagnosis
 T ; Treatment

Gordis L. Epidemiology. WB Saunders Company. 1996

 Definition ; The course of a disease from onset
(inception) to resolution.

Stages

Progress to a fatal termination

Stage of
Pre-symptomatic Clinically
pathologic Remission and relapses
stage manifest disease
onset
Regress spontaneously,
Definition & Stages leading to recovery

Risk Factors Precursors Effect of Treatment Prognostic factor

 THE NATURAL HISTORY OF A DISEASE
STIMULUS to
HOST REACTION RECOVERY
the HOST
interrelation of
Agent, Host and Latent Period (Pre- Symptoms, with or without Defects,
Environmental symptomatic) Signs(Clinical) Disability
factors
PREPATHOGE
PERIOD OF PATHOGENESIS
NESIS
Health
Promotion Disability Limitation
Specific Early Diagnosis and Prompt
Protection Treatment,
Rehabilitation

PRIMARY SECONDARY
TREATMENT TERTIARY PREVENTION
PREVENTION PREVENTION

(Leavell's Level of Application of Preventive Medicine)

 TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious Non-infectious

Exposure Onset
Bagaimana tanda orang yang
terkena HIV ?
Bagaimana HIV menjadi Aids?
Nutrigenomics (Nurture)
Nutrigenomics
◦ Nutrition +
Transcription
genomics Factor Nucleus
◦ How do nutrients Gene
alter gene DNA Target
expression?
Change mRNA

Essential Protein (< or >)

and non-
essential
nutrients Biological
responses in
cell process(es)
Perkembangan Janin dalam kandungan
The Epigenetic Hallmarks of
Senescence and Aging
Dampak yang terjadi saat terjadi gangguan 1000 HPK
MALNUTRISI PADA USIA <2TAHUN SANGAT MEMPENGARUHI “GOLDEN PERIOD” ANAK
Perkembangan otak sangat signifikan saat usia 1000 HPK
PENGARUH GIZI IBU
 DECREASING PROPORTIONS
At birth, the head represents one-quarter of the neonate’s head.
By adulthood, the head is only one-eighth the size of the body
LIFE CYCLE
HAL YANG DITAKUTKAN DARI LINGKARAN MALNUTRISI YANG TERUS
BERLANJUT
Perempuan perlu perhatian
khusus??
Akar trans-generasi penyakit
kronis
 INDONESIA MEMILIKI ANGKA PENDERITA STUNTING >40%
Indonesia termasuk salah satu dari 17 negara dari 193 negara yang mempunyai 3 masalah gizi tinggi pada balita:
Stunting, Wasting dan Gemuk
 Nutritional Status:
(status gizi=keadaan gizi)

Keadaan tubuh sebagai akibat dari

keseimbangan antara konsumsi dan
pemanfaatan zat gizi.
Normal vs malnutrition.
Community nutritional
assessment
To map out the magnitude and
geographical distribution of
malnutrition
Discover and analyze the ecological
factors that directly or indirectly
responsible
Suggest appropriate corrective
measures

Preliminary step for further action

 Malnutrition
A pathological state resulting from a relative or absolute
deficiency or excess of one or more essential nutrients.
• Overnutrition
• Undernutrition
• Specific deficiency
• Imbalance
Overnutrition

resulting from the

consumption of an
excessive quantity
of food, over an
extended period of
time
Undernutrition

resultingfrom the
consumption of an
inadequate quantity
of food, over an
extended period of
time
Epigenetic Inheritance
Genetic tags are 
passed down
through generations
When the zygote is
formed many
epigenetic tags are
removed from the
chromosomes of the
parents, but some
remain
Epigenetic Inheritance cont.
 Previously believed
that genetic
information was
passed through DNA
only
 Studies in the field of
epigenetics shows
that parent’s
experiences are
passed on to offspring
through epigenetic
tags
 Environment &Epigenome

Mounting evidence
suggests that
fetuses are
surprisingly
susceptible to
outside influences
such as
environmental
pollutants,
pesticides, and other
toxins.
Agouti “Twin” Sisters
 Coat color serves as a sensor
for the degree of methylation present
Relationships within genetic : random sequence
epigenetics, gene regulation, induced polymorphism
Contrasting phenotypes

duplication

deletion normal dosage duplication

 Nutrigenomics Definition
 Analyzing the effects of diet on the activity of on
individual’s genes and health and the effect of an
individuals genes on metabolism of dietary chemicals
 Diet = nutritional science
Activity of genes = molecular biology
Individual = genetics/genomics
Health = physiology
 A systems biology science : Multi - disciplinary

Nutrient is independent variable

Nutrient Gene Expression

Gene expression is independent variable

 What is Nutrigenomics?
Nutrigenomics is the science that examines
the response of individuals to food compounds
using post-genomic and related technologies.
The long-term aim of nutrigenomics is to
understand how the whole body responds to
real foods using an integrated approach.
 Studies using this approach can examine
people (i.e. populations, sub-populations -
based on genes or disease - and individuals),
food, life-stage and life-style without
preconceived ideas.
9/24/19 68
Genes – Lifestyle – Calories

9/24/19 69
 Nutrigenomics
Target Genes
Foods Signatures
Mechanisms Nutrition Profiles
Pathways Biomarkers

Molecular Nutrition Nutritional

& Genomics Systems Biology
•Identification of dietary signals
•Measurement of stress signatures
•Identification of dietary sensors
•Identification of early biomarkers
•Identification of target genes
•Reconstruction of signaling pathways
Small research groups Large research consortia
Small budgets Big money

Complexity
9/24/19 70
Molecular nutrition
9/24/19 71
 Nutrients acts as dietary
signals
Nutritional factors

Transcription factors

Gene transcription

Energy Cell
homeostasis proliferation

Nutrient
absorption
9/24/19 72
Transcription-factor pathways
mediating nutrient-gene interaction

9/24/19 73
 Gene regulation Dietary Gene expression Prevention of
by nutrients Programming Signatures Metabolic Syndrome

Nutrient-related cellular sensing + Metabolic stress

Nutrients Signaling Cells Genes Proteins Functions Organs Animal Humans Healthy Food

Transporters
Transporters Target
Target Metabolic
Metabolic Mouse
Mouse
Transcription
Transcription genes
genes Implications
Implications Models
Models
factors
factors of
of nutrients
nutrients Metabolites
Metabolites
Lipids
Lipids Enterocytes
Enterocytes Proteins
Proteins Intestine
Intestine
Fatty
Fatty acids
acids Hepatocytes
Hepatocytes Post-
Post- Liver,
Liver, Muscle
Muscle Intervention
Intervention
Sugars
Sugars Adipocytes
Adipocytes translational
translational Blood
Blood Studies
Studies
Calcium
Calcium Lymphocytes
Lymphocytes Regulation
Regulation Adipose
Adipose tissue
tissue

Signaling Cells Genes Proteins Functions Organs Animal Humans

Diet-related organ sensing, Sensitivity genes + Molecular Phenotype

Molecular Biology Transcriptome Metabolomics Early Molecular

Tools Proteome Systems Biology Biomarkers
9/24/19 74
 Two Strategies
(1) The traditional hypothesis-driven approach: specific genes and
proteins, the expression of which is influenced by nutrients, are
identified using genomics tools — such as transcriptomics, proteomics
and metabolomics — which subsequently allows the regulatory
pathways through which diet influences homeostasis to be identified .
Transgenic mouse models and cellular models are essential tools .

provide us with detailed molecular data on the interaction

between nutrition and the genome .
(2) The SYSTEMS BIOLOGY approach: gene, protein and metabolite
signatures that are associated with specific nutrients, or nutritional
regimes, are catalogued, and might provide ‘early warning’molecular
biomarkers for nutrient-induced changes to homeostasis.

Be more important for human nutrition, given the difficulty of

collecting tissue samples from ‘healthy’ individuals.
9/24/19 75
Caloric restriction–induced alterations in
gene expression

Science
9/24/19 (1999) 285:1390-139
76
 Conclusion of gene expression profile of
aging and its retardation by caloric restriction

9/24/19 77

Science (1999) 285:1390-13

Metabolic Syndrome and
Diabetes
Ageing Increased
Increased
Genes Ageing
Genes lipolysis
lipolysis in
in
visceral
visceral fat
fat Increased
Increased
gluconeogenesis
gluconeogenesis
Muscle
Muscle insulin
insulin in
in liver
liver
resistence
resistence Increased
fatty acids levels
Increased
hyperinsulemia glucose output
Obesity
Obesity
Decreased
Decreased
glucose
glucose
bb Cell
Cell tolerance
tolerance
compensation
compensation
bb Cell
Cell Decreased Diabetes
Diabetes
decompensation
decompensation insulin
secretion
9/24/19 78
Signatures of health & stress -The “two hits”:
Metabolic and pro-inflammatory stress

9/24/19 79
Strategies we need in gene-nutrient
interactions

9/24/19 80
 Nutrigenetics Definition
 Effects of individual genetic variation in response
to nutrient
 Any two individuals share 99% of their DNA sequence
 Most common form of variation

 Single nucleotide polymorphism (SNP)

 Changes in single base pair
 Occur ~ 1 in every 1000bp of human genome
(~ 3 million in human genome)

 SNPs may alter regulation of gene expression,

mRNA processing (splicing, half-life etc) and protein
activities
Micronutrients that act directly or indirectly as
antioxidants or influence DNA expression

Vitamin Vitamin
A C

Vitamin Vitamin
B12 B6

Vitamin Vitamin
E B3

Folic Vitamin
acid B2

Vitamin Zn,Se,Fe
D Mg, Cu
Antioxidants evolutions & Human
Health

Threat and management of

deleterious radicals generated
by cellular respiration

Membrane
Damage Mitochhondria
l DNA
Free
radicals Damage
+
O2

Su AT
pe P
Superoxide

ro en
dismutase

xid er
e r gy
ad
i ca
H2O2

l
Catalase

H2O and O2 + Glucose

O2
Nuclear DNA Damage
Free Radicals and Diseases
Do nutrients affect gene
expression?
◦ Vitamin E regulates protein kinase C activity in smooth
muscle cells (Azzi 1991)
◦ Modulates the expression of the hepatic alpha-tocopherol
transfer protein (Hosomi 1997)
◦ Tocopherol-dependent transcription factor (tocopherol
associated protein, TAP) has been identified (Stocker
1999)
◦ CoQ10 in human muscle cells has shown effects on 12,000
genes (Linnane 2002)
◦ Vitamin D3 affects 20,000 genes in human prostate cancer
cells (Krishnan 2003)
◦ EGb 761 alters mRNA levels of the GLUT3 in hippocampal
neurons, increasing neuronal glucose supply in rats (Loffler
2001)
◦ L-leucine interacts with multiple genes via mTOR and Akt
pathways
Iodine deficiency disorders
Kurang vitamin A
Defisiensi Folat
Nutritional assessment

Indirect Direct
* dietary survey * biochemical test
* biophysical methods
* assessment of * nutritional
ecological anthropometry
factors * clinical sign
 Dietary survey

National level Household level Individual level

• Food balance • Food account •Single 24 hour recall
sheet • List recall •Multiple 24 hour recall
• Market data base •Food frequency
•Food diary record
•Weighed assessment

Gibson RS 1990. Principles of nutritional assessment

Human growth is influenced by
1. Biological determinants :
sex, intra uterine environment,
birth order, birth weight, parental
size, genetic constitution

2. Environmental :
Nutrition, Climate, living
condition,socio-economic condition,
diseases,
psychological factor etc
*Anthropometric Measurements =
picture of human growth at different age
level (from fetoes to adulthood):

 height/length, weight
 upper arm circumference (UAC/LILA)
 head circumference
 BMI (body Mass Index)
 Skinfold thickness

 raw measurements do not mean

anything, if not compared to
REFERENCE or STANDARDS.
Body weight
Body length & height
Mid Upper Arm Circumference
Head circumference
Triceps Skin Fold
 Knee height measurement

A valid index of linear growth, can detect growth increments in

children more readily and over a short time period in compared
to height measurements.
 Have a greater precision.
 In infants: the growth is not linear, with a period of slow and
then accelerated growth
 In adults: highly correlated with stature & maybe used to
estimate height in persons with severe spinal curvature or who
are unable to stand. The available formula are for Caucasian and
African-American. Population-specific equations maybe
necessary.
 Body Weight can also be calculated from an equation based on
the values of calf circ, knee height, muac, Subscap skinfold (for a
selected population living in US)
Arm Span

Is also highly correlated with stature.

Especially useful for assessing retrospective
measurement that is stature prior to any age
associated loss in the elderly.
It is difficult to measure in non ambulatory
persons and individuals with significant chest
andspinal deformities.
A study showed that knee height is a more
valid estimate of maximum stature during
adulthood than arm span
 Elbow breadth
Is a good measure of skeletal dimensions/
frame size
Highly associated with lean body mass and
muscle size.
 Anthropometric indices, not the raw measurements, are
interpreted and evaluated
 For chidren: WHZ (for wasting) & HAZ (for stunting) are
the preferred anthropometric indices of body size.
 Anthropometric indices can be used at individual and
population levels for : assess nutritional status,
screening & response during intervention
 At population level can be also used to identify the
determinants and consequences of malnutrition and for
nutritional surveillance.
Interpretation and evalution of
anthropometric data
KMS
 WHZ HAZ WAZ

Usefullness in populations where 1 4 4

age is uncertain
Usefullness in identifying wasted 1 4 3
children
Sensitivity to weight change over 1 4 2
a sort period of time
Usefullness in identifying stunted 4 1 2
children

Selecting the appropriate indices

1:excellent, 4: poor
 Klasifikasi status gizi
Indeks Status Keterangan
BB/U Gizi lebih >= 2 SD
Gizi baik - 2 SD s/d +2 SD
Gizi kurang -2 SD s/d – 3 SD
Gizi buruk < - 3 SD
TB/U Normal -2 SD s/d + 2 SD
Pendek (stunted) < - 2SD
BB/TB Gemuk >= 2 SD
Normal -2 SD s/d + 2 SD
Kurus (wasted) < -2 SD s/d – 3 SD
Sangat kurus < - 3 SD
Interpretasi berdasar kombinasi indikator

Combination Interpretation
BB/TB: N, BB/U: R, TB/U: R Normally fed, with past history of malnutrition

BB/TB: N, BB/U: N, TB/U: N Normal

BB/TB: N, BB/U: T, TB/U: T Tall, normally nourished

BB/TB: R, BB/U:R, TB/U: T Presently underfed ++

BB/TB: R, BB/U: R, TB/U: N Presently underfed +

BB/TB: R, BB/U: N, TB/U: T Presently underfed

BB/TB: T, BB/U: T, TB/U: R Obese ++

BB/TB: T, BB/U: N, TB/U: R Overfed with past history of malnutrition

BB/TB: T, BB/U: T, TB/U: N Overfed but not necessarily obese

The advantages of anthropometric assessment

• simple, safe, inexpensive, non invasive

• unskilled personnel can perform measurement procedures
• precise and accurate
• may be used to evaluate changes in nutritional status over time
and from one generation to the next
• can assist in the identification of mild to moderate malnutrition,
as well as severe states of malnutrition
Limitations of anthropometric assessment

Relatively insensitive, cannot detect disturbance in

nutritional status over short periods of time or identify
specific nutrients deficiencies

Unable to distinguish disturbances in growth or body

composition induced by specific nutrient (e.g. Zinc)
deficiencies from those caused by imbalances in protein
and energy intake

Certain non-nutritional factors (disease, genetics, diurnal

variation) can reduce the specificity and sensitivity
 Sources of error in nutritional anthropometry

• Measurements error : examiner, instrument, object

• Alteration in the composition and physical properties of
certain tissues (tissue hydration, oedema, hepatomegaly)
• Invalid assumptions : e.g. skin fold
in fact the relationship between subcutaneous and
internal fat is non linier
 Skinfold thickness measurements:
◦ Triceps skinfold
◦ Biceps skinfold
◦ Subscapular skinfold
◦ Suprailiac skinfold
◦ Midaxillary skinfold
 Multiple skinfold measurements can be used for
measuring percent body fat

Anthropometric assessment of body

composition
 Waist hip circumference ratio: >1.0 for men & >0.85 for
women indicated abdominal fat accumulation & increase
risk of cardiovascular complications
 Waist circumference: alone is the preferred indicator of
fat loss. For urban Asians: >80cm for women & >90cm
for men indicated central obesity
 Limb fat area: to estimate body fat
 Percent body fat can be predicted by several skinfld
measurements

Anthropometric assessment of body

composition