EXPOSURE DAN OUTCOME

GIZI-PTM

DODIK BRIAWAN

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 Tantangan buat ahli gizi
(Kuliah B Woro)

Inovasi gizi apa:

untuk pencegahan & pengendalian faktor risiko PTM ???

Jawaban:
Perlu memahami NCDs risk factors/prevention factors
Menemukan intervensi yg tepat utk NCDs
 Exposure Outcome (NCDs)
(risk/prevention)

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 Exposure
ART -UGM
Outcome:

The term “exposure” can be broadly applied to any factor

that may1.beDose
associated with an outcome of interest
2. Intensity
3. Duration
The “outcome” of a study is a broad term for any defined
disease, state of health, health-related event or death. In
some studies, there may be multiple outcomes
 Exposure
ART -UGM
Outcome:

1. Dose
2. Intensity
3. Duration
Key Issues Exposure
ART UGM - Outcome:

• Method of assessment
1.
• Dose
Laboratory
2.
• Intensity(field of study)
Authority
3.
• Duration
Skills
 Nutritional Assessment

• Anthropometric methods
• Biochemical, laboratory methods
• Clinical methods
• Dietary assessment methods

How do you implemented this ABCD methods into E-O parameters?

 Choice of biochemical markers:

1. Short term: feces, urine, serum/plasma,

breast milk
2. Medium/long term: red cells, white cells,
hair, nails, adipose tissues

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 Exposure/Health assessment:

1. Personal interviews
2. Self administered questionnaires
3. Diaries
4. Observation
5. Routine record
6. Physical/chemical measurement on the environment
7. Physical/chemical measurement on the person

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 Exposure?

Generic factor that is presence of the substance

under study:

ranging from micro to macro- level (population, soc-

eco individual, physic-environment, indv life style);
exposure at the level of body, organ, cell or molecule

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 Aspect of exposure:
1. Dose
2. Intensity
3. Duration
4. Comulative exposure

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 Measuring dietary exposure must be considered:

1. Food consist of many substances

2. Food substances have different functions and
physiological effects
3. Isolation of component diet may appear different
with the natural food
4. A nutrient may have more than one functions
(different in the outcomes)
5. Nutrients requirement are different in growth, age,
pregnancy or state of infection
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 Measuring dietary exposure must be considered:

6. The nutrients may directly or indirectly affect the

diseases
7. The effect of one nutrient may different at the level of
another nutrients.
8. Food intakes is not equivalent to biological
availability
9. Some nutrients have bioequivalence
(ex. Niacin synthesized from Trypthophan)

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 Measuring dietary exposure must be considered:

10. Critical time period of outcome development at the level

of nutrients intake
(ex. Folic Acid with NTD)
11. A nutrient measured in blood serum may not reflect the
status of nutrient
(ex. Fe serum)

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 How to Assessed PA
Metode Subjektif:
• International Physical Activity Questionnaire (IPAQ),
• Physical Activity Recall (PAR),
• Habitual Activity Questionnaire (HAQ),
• Physical Activity Questionnaire for Older Children
(PAQ-C),
• Physical Activity Questionnaire for Adolescent
(PAQA),
• Physical Activity Scale for Elderly (PASE),
• The Rapid Assessment of Physical Activity (RAPA)
 What the parameters for NCDs?

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 OUTCOME - OBESITY

• Overweight and obesity are defined as abnormal or

excessive fat accumulation that may impair health.
• How to measure obesity?
 kg .
A working example of BMI m2
Kirsten BMI = weight (kg)
Weight: 78kg height (m) x height (m)

Height: 1.70m = . 78 .
1.70 x 1.70

= 27 Kirsten is overweight.
Recommended BMI range
Underweight less than 18.5
Normal 18.5 - less than 25
Overweight 25 (22.9)- less than 30
Obese 30 - 40
Very obese over 40
Waist circumference
This measurement provides information about how your
weight is distributed around your body.

It is understood that a greater waist circumference can

lead to a higher chance of getting diseases such as,
Type 2 diabetes, heart disease or high blood pressure.
 Waist circumference

Recommended Increased risk Greatest risk

Male < 94cm 94-101cm >102cm

Female <80cm 80-87 cm >88cm

WHO Diet, nutrition and the prevention of Chronic Diseases' 2003

The above figures are for Caucasians.

The ‘recommended’ numbers for South Asians (Chinese, Malay and
Asian–Indian) is 85cm for males and <80cm for females.
 The health consequences of overweight and obesity?

 Cardiovascular Conditions  Orthopedic Conditions

• Hyperlipidemia • Blounts Disease
• Hypertension (HTN) • Hip Disorders (SCFE)

 Endocrine Conditions  Psychological Conditions

• Dysmetabolic Syndrome • Depression/Self-Esteem
• Type 2 Diabetes • Substance Abuse
• Impaired Glucose Tolerance • Disordered Eating
• Menstrual Irregularities • Discrimination
• Polycystic Ovarian Syndrome
• Accelerated Growth
 Pulmonary Conditions
• Asthma
 Gastrointestinal Conditions
• Sleep Apnea
• Non-Alcoholic Fatty Liver Disease
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(NAFLD) 22
• Gallstones
 OUTCOME - DIABETES
Diabetes mellitus (DM) is a group of diseases characterized by
high levels of blood glucose resulting from defects in insulin
production, insulin action, or both.
The term DM describes a metabolic disorder of multiple
aetiology characterized by chronic hyperglycaemia with
disturbances of carbohydrate, fat and protein metabolism
resulting from defects in insulin
The effects of DM include long–term damage, dysfunction and
failure of various organs.
 Diabetes Long-term Effects-OUTCOME
The long–term effects of DM include progressive development
of the specific complications of retinopathy with potential
blindness, nephropathy that may lead to renal failure, and/or
neuropathy with risk of foot ulcers, amputation, Charcot joints,
and features of autonomic dysfunction, including sexual
dysfunction.

People with diabetes are at increased risk of cardiovascular,

peripheral vascular and cerebrovascular disease.
Diagnosis of Diabetes Mellitus
 OUTCOME – CVDs

CVDs are a group of disorders of the heart and blood vessels, includes:
 coronary heart disease – dis. of the blood vessels supplying the heart muscle;
 cerebrovascular disease – dis. of the blood vessels supplying the brain;
 peripheral arterial disease – dis. of blood vessels supplying the arms and legs;
 rheumatic heart disease – damage to the heart muscle and heart valves from
rheumatic fever;
 congenital heart disease – malformations of heart structure existing at birth;
 deep vein thrombosis and pulmonary embolism – blood clots in the leg veins,
which can dislodge and move to the heart and lungs.
Ex: Potential Components of a “Multimarker” Approach

Daniels LB. Curr CV Risk Rep 2009.

 OUTCOME - CANCER

 Cancer is a generic term for a large group of diseases

that can affect any part of the body. Other terms used
are malignant tumours and neoplasms.
 One defining feature of cancer is the rapid creation of
abnormal cells that grow beyond their usual boundaries,
and which can then invade adjoining parts of the body
and spread to other organs, the latter process is referred
to as metastasizing.
 Metastases are the major cause of death from cancer.
 Serum Protein Biomarkers for Oral Cancer

 Interleukin-6 [IL-6]
 Interleukin-8 [IL-8]
 Vascular Endothelial Growth Factor [VEGF]
 Vascular Endothelial Growth Factor C [VEGF-C]

Trikha, M.; Corringham, R.; Klein, B.; Rossi, J. Clin. Cancer Res. 2003, 9, 4653-4665
Hebert, C. A.; Baker, J. B. Cancer Invest. 1993, 11, 743-750
O-charoenrat, O.; Rhys-Evans, P.; Eccles, S. A. Cancer 2001, 92, 556-568
 OUTCOME -COPD
• Penyakit Paru Obstruktif Kronik (PPOK)
• Chronic obstructive pulmonary disease (COPD) is a life-threatening lung
disease that interferes with normal breathing – it is more than a “smoker’s
cough”.
• The primary cause of COPD is tobacco smoke (through tobacco use or
second-hand smoke).
• COPD is not curable, but treatment can slow the progress of the disease.
• Total deaths from COPD are projected to increase by more than 30% in the
next 10 years without interventions to cut risks, particularly exposure to
tobacco smoke.
 CPOD Diagnose
•Tes darah, untuk memastikan apakah pasien menderita penyakit
lain, seperti anemia dan polisitemia, yang memiliki gejala serupa
dengan PPOK. Tes darah juga digunakan untuk memeriksa
antitripsin alfa-1.
•Analisis gas darah arteri. Tes ini untuk melihat kandungan
oksigen dan karbondioksida dalam darah.
 CPOD Diagnose

• Foto Rontgen dada. Foto Rontgen dada dilakukan untuk mendeteksi

ganguan pada paru-paru.
• CT scan, yang dapat menunjukkan gambaran paru-paru secara
lebih detail.
• Elektrokardiogram (EKG) dan ekokardiogram, guna memeriksa
kondisi jantung.
• Pengambilan sampel dahak.
 link of exposure and disease

On a population basis
•An increase in the level of a causal factor will be
accompanied by an increase in the incidence of
disease (all other things being equal).
•If the causal factor is eliminated or reduced, the
frequency of disease will decline
 MEASURING RELATIVE RISK

RR = 1, there is no association between E and O

RR > 1, an increased risk among those expose
(positive association)
RR < 1, an inverse association or decrease risk
among those expose
(negative association)

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Review jurnal (meta-analysis)

PETO GRAPH
Outcome A
Study
A
B
C
D
E

Total

Placebo 0 Drug
 Web of NCDs Causation

• There is no single cause

• Causes of disease are interacting
• Illustrates the interconnection of
possible causes
Web of Causation - CHD
1. Consistency of findings
2. Strength of association
3. Dose-response effect (biological
gradient)
4. Temporal sequence
5. Biological plausibility
6. Coherence with established facts
7. Specificity of association