Introduction to

Public Health Nutrition

Shelbay G. Blanco, MD, MPH
Preventive and Social Medicine III
Nutrition
•study of food and how the body uses it to be
healthy, socially active and economically
productive
•the study of food in relation to health
•the science of food, the nutrients and other
substances
Nutrition
•the theory and practices of nutrition as science thru
organized community effort
• Its actions, interaction and balance in relation to health
and disease
• The process by which the organism ingests, digests,
transports, stores, utilizes and excretes food substances
•the prevention, promotion, conservation of health
thru proper nutrition
 Public Health
• Branch of medicine which deals with the
preventive, promotive, and curative health
services through organized community
efforts.
• A combination of sciences, skills and beliefs
directed toward maintenance and
improvement of health of all people through
collective or social actions.
• Mission: is to assure conditions in which
people can live healthy.
Public Health Nutrition
•Studies relationship between dietary intake and
disease,
• Uses tools of nutritional epidemiology,
• Knowledge applied for nutrition intervention to
prevent disease
• Institutionalizes national nutrition programs for global
prevention, control and elimination of nutritional
disorders
Multidisciplinary Approach to Public Health Nutrition

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Basic Nutrition Values
• Basic Family Values
• Proper nutrition is a basic human right of a child
• Basic Community Values
• The responsibility of leadership is to encourage that the right and adequate food is
produced in the community
• Community leaders must see to it that adequate food is available and accessible to
the family
• Basic Health Provider Values
• The responsibility of every health/nutrition manager/worker is to provide the right
kind of Knowledge and skills to the family
• Appropriate nutrition and health services must be available and accessible to the
family
• Make nutrition and health is a "way of life"
Importance of Nutrition
• It is needed for growth and development of the
different parts of the body
• Provide energy for better work capacity
• Provide resistance to infection
• It is needed for the repair and maintenance of body
issues
• Food
• any substance when ingested or eaten
nourishes the body.

• Digestion
• it is a mechanical and chemical
breakdown of food into smaller components.
• Absorption
• process where the nutrients from foods are
absorb by the body into the bloodstreams.

• Metabolism
• chemical process of transforming foods into
other substance to sustain life.
Enzymes
• an organic catalyst that are protein in nature and
are produced by living cells.

Nutritional Status
• the condition of the body resulting from the
utilization of essential nutrients.
• Calorie
•fuel potential in a food. One calorie represents the
amount of heat required to raise one liter of water
one degree Celsius.

• Malnutrition
•the condition of the body resulting from a lack of
one or more essential nutrients or due to excessive
nutrient supply.
What Are Nutrients?
• Nutrients: the chemicals in foods that are critical to
human growth and function.
•carbohydrates
•fats and oils
• proteins
•vitamins
• minerals
•water
What Are Nutrients?
• Macronutrients:
• nutrients required in relatively large amounts.
• Provide energy to our bodies
• Carbohydrates, fats and oils, proteins
• Micronutrients:
• nutrients required in smaller amounts.
• Vitamins and minerals
Food Groups
• Food guides translate quantitative nutritional requirements
into simple, practical and non- technical language using
available and common foods of the country.

Dietary Guidelines
• strategies to promote appropriate diets and related health
practices to achieve the goal of improving the nutritional
condition.
The 3 Main Food Groups:
• Body-building foods
• foods that supply good quality proteins, some vitamins and
minerals.
• Energy foods
• mostly of rice and other cereals, starches, sugars and fats
contribute the bulk of Calories
• Regulating foods
• composed of fruits and vegetables that provide vitamins and
minerals, particularly ascorbic acid and pro vitamin A.
Dietary Reference Intakes
• Dietary Reference Intakes (DRIs) = recommended nutrient
intakes
• Estimated Average Requirement (EAR)
• Recommended Dietary Allowance (RDA)
• Tolerable Upper Intake Level (UL)
•Acceptable Macronutrient Distribution Range (AMDR)—
percent of total daily calories
• 45-65% as carbohydrate
• 20-35% as fat
• 10-35% as protein
Recommended Dietary Allowance

• the information of nutrient allowance for the

maintenance of good health.
• A tool for assessing a dietary intake of the population
group.
• This emphasize the amount of foods or diet.
Recommended Energy Nutrient
Intakes (RENI)
• A new standard replacing RDA, emphasizing on recommending on the
nutrients rather than food or diet.
• serve as a guide for designing nutrition and health intervention towards
an improvement of the health of the population.
• used to denote recommendations for energy and 21 nutrients including
protein, folate, calcium, and zinc for the maintenance of health and
well-being of nearly all healthy persons in the population.
• a guide to good nutrition that can help in food choices
TABLE 44-1 Reference Nutrient Intakes of Vitamins and Minerals, UK 1991

VltB, VltB, Niacin VltB4 VltB,, Folate vnc vn a VttD Ca P Mg Fe ZU Cm Se

Age (mg) (mg) (mg) (mg) (HI) (M9) (mg) <M9» (mg) (mg) (mg) (mg) (mg) (mg) (W) w
0-3 mo 0.2 0.4 3 03 0-3 SO 25 350 85 525 400 55 1.7 40 03 10 SO

4-6 mo 0.2 0.4 3 03 0.3 50 25 350 85 525 400 60 4.3 4.0 03 13 60

7-9 mo 03 0.4 4 0.3 0.4 50 25 350 7 525 400 75 76 5.0 03 10 60

10-12 mo 0.3 0.4 5 0.4 0.4 50 25 350 7 525 400 80 73 50 03 10 60

1-3y 0.5 06 8 0.7 05 70 30 400 7 350 270 85 6.9 5.0 0.4 15 70

4/,y 0.7 0.8 11 0.9 0.8 100 30 SOO - 450 350 120 6.1 63 06 20 100

7-10 y 0.7 1.0 12 1.0 1.0 150 30 500 - 550 450 200 8.7 7.0 0.7 30 110

Malos -
11-14y 0.9 1-2 15 13 13 200 35 600 - 1000 775 280 113 9.0 0.8 45 130

1S-18y 1.1 13 18 15 15 200 40 700 - 1000 775 300 113 93 1-0 70 140

19-soy 1.0 13 17 1.4 15 200 40 700 - 700 550 300 8.7 93 13 75 140

so. y 0.9 13 16 1.4 15 200 40 700 10 700 SSO 300 87 93 13 75 140

Females

11-14y 0.7 1.1 12 1.0 13 200 35 600 - 800 625 280 14.8 9.0 08 45 130

15-18y 08 1.1 14 13 15 200 40 600 - 800 6254 300 148 7X> IO 60 140

19S0y 0.8 1.1 13 13 15 200 40 600 - 700 SSO 270 140 70 13 60 140

5O»y 0.8 1.1 12 13 15 200 40 600 10 700 550 270 8.7 70 13 60 140

Pregnant 40.1 40.3 - - - 4100 410 4100 10 - - -

Lactating 40.1 403 ♦2 - 405 ♦60 ♦ 30 4350 10 4550 ♦ 440 ♦ 50 ♦60 ♦0 3 415

Department of Health. Ihetary HHnent e Vaktrx lot food I nergyand Nutrient* ta rhe Ifrutnl Kngdam HMSO, L 1991
MY PYRAMID
MyPyramid
 MY PYRAMID
MEAT & BEANS
GRAINS VEGETABLES FRUITS MILK
Vary your veggies Focus on fruits Get ku ciaurwuntooils Go ban with proton

Eatattat Jmolvrhole- Eat more dart-peen veggies Eat a variety of kti Cokm-tatorfar-keenton Chasse Ion-tar«lean
grain cereals, breads, He brace* sparsach. and other you choose m*. yoguet meats and posiry
crackers. rice, or paste dart leafy peens Choose fresh, frocen. and ctw mi products
everyday canned, or dned Inat Bake C bn* got grid

Eat more orange vegetables 1 you don't or cant

1 ot a about 1 slice ol lie carrots and sweetpoatces Co easy on hat mcb constant mi, choose Vary you protwrouene-

bread about 1 cup ot lactoselree products or choose more ksh beans,

breakfast cere* or 'ft cup Eat more dry beans and peas other catoum sources peas. nuts, and seeds

of cooled rice, cereal lie prto beans kidney beans, such as fortified foods

or pasta and lento and beverages

For a 2OOO-calone diet you need the amounts below horn each food poup So tod the amounts IM arenpM lor yen,«o to MyPyrattolpo.

Get 3 cups every day,

Eat 6 oz every day Eat 2'/> cups every day Eat 2 cups every day Eat S'/t 02 every day
tar Uk ** 2 II < III
MY PYRAMID
Mediterranean Diet Pyramid
A ajpu** *•> 4rt»<»w». JkmfrAy «ri"K
Food Exchange List
• A classification or grouping of common foods in terms of equivalent
amounts of Carbohydrates, Protein, Fat and Calories
• The word exchange refers to the fact that each item on a particular
list in the portion listed may be interchanged with any other food
item on the same list.
• An exchange can be explained as a substitution, choice, or serving.
Carbohydrates
• Organic compounds that consist of carbon, hydrogen and oxygen
• Primary source of fuel especially for the brain.
• Provide 4 kcal per gram.
• Carbohydrates are found in grains (wheat, rice), vegetables, fruits, and
legumes
• 2 major categories of carbohydrates:
• Simple or refined carbohydrates
• Complex carbohydrates are long complex chains of sugars bound together
Family of Carbohydrates
• Simple or refined
• Monosaccharides
• Disaccharides
• Complex
• Starch
• Dietary Fiber
• Insoluble Fiber
• Soluble Fiber
• Other Carbohydrates
• Organic Acids
• Sugar Alcohols
Functions of Carbohydrates
• Supplies energy to the body
• Spares protein from being used for energy
• Lactose: milk sugar increases absorption of calcium and phosphorus
and promotes growth of beneficial bacteria
• Provides bulk to the diet and gives feelings of satisfaction
• Fructooligosaccharides - a complex carbohydrate that acts likle
soluble fiber; it lowers intestinal pH by producing short-chain fatty
acids; it is found in banana, barley, garlic, grains, onions and tomatoes
• Inulin - increases production of bifidobacteria and helps increase
resistance to infection
GLYCEMIC INDEX
• a ranking of carbohydrates on a scale from 0 to 100 according to the
extent to which they raise blood sugar (glucose) levels after eating.
• Foods with a high Gl are those which are rapidly digested, absorbed
and metabolised and result in marked fluctuations in blood sugar
(glucose) levels.
• Low Gl carbohydrates - the ones that produce smaller fluctuations in
your blood glucose and insulin levels - is one of the secrets to long­
term health, reducing your risk of type 2 diabetes and heart disease.
• It is also one of the keys to maintaining weight loss.
GLYCEMIC INDEX
• a relative ranking of carbohydrate in foods according to how they affect
blood glucose levels.
• Carbohydrates with a low Gl value (55 or less) are more slowly digested,
absorbed and metabolised and cause a lower and slower rise in blood
glucose and, therefore insulin levels.
GLYCEMIC INDEX

TIME/HOURS

The amount of carbohydrate in the reference

and test food must be the same.
 XQ 110
Food Item
Maltose
Food Item
Banana 36
g Food Item
Chick peas

■c 100 Glucose Sucrose 36 Lima beans

a Pl
97
Potato, russet, baked
Parsnips
Sweet corn
Bran
36
34
Yogurt
Pear
92 Carrots Green peas 34 Milk, whole
87 Honey Potato chips 32 Milk, skim

M Pl Potato, Sweet potato 29 Kidney beans

instant mashed White spaghetti
s
29 Lentils
80 Cornflakes Oatmeal 26 Peach

H 72
72
Whole-wheat bread
White rice
Grapes
Whole-wheat
26
25
Grapefruit
Plum

§ 69
67
White bread
Shredded wheat
spaghetti
Orange
23
20
Cherries
Fructose
66 Brown rice Apple 15 Soybeans
64 Raisins Tomato 13 Peanuts
64 Beets Ice cream
 Grain/Starch Grain/Starch Vegetable Fruit Dain Protein Swets

LOW L!X
F 31
PtMtt 21
%
44 sweetened
Beans dried,
20 not specified 40
&w
53 Mk c nxo late Lentils, icecream lowfat7'
54 artfoaly not specified 41 Cake pound 77
55 sweetened 34 Kidney beans 41 Oatmeal cookies 79
Sweet potato Peach, fresh 60 Mik. regular 39 Butter beans 43
acom 63 Sqm* 43 Wv% MODERATE
wMe 66 M i s*m'nonfat45 HohF'uctO*
lour bread 95 boiled 67 Yogurt low fat Lima beans _____
Potato new 75 frut sugar sweet 47 baby frozen 46 Pasty
Banana 77 Mik. chocolate. Chick peas Muesli Bars
MODERATE sugar sweetened 49 '-x--i- icecream
earned
MODERATE
Frurt cocktail 79 MOOERATE
Navy bean* be
Pinto beans Sucrose
80 Icecream low fat 71 Blade-eyed
HIGH Chick peas
Potato mashed 1 91 HIGH canned
MMfli 93 Icecream 87 lentil soup.
Pumpemckei Punpkn 94 CMM
fread brahamsl F'enchfnes Pinto beans
Bran Bugs C'ackers 1 Potato HIGH canned
K mcro.vaved Watermelon 103 Baked beans
Potto Itttt Dates 141 canned
Popcorn Potato baked Kidney beans, Donut
Rice b'owr Parents canned Wes
74
Lentils canned 74Vania Wafers
Tapoca boiled
MODERATE with milk 11
. 86 Pretzels 11
117 soup 92 Honey 12
-orr’iaKes $ Green pea Isoup Glucose 13
keChex canned 94 Makose 15
ke instant 123 Tofu frozen
tour bread French baguette 1 dessert
noncairy 164
 Fats and Lipids
• Fats and oils are composed of lipids, molecules that are insoluble in
water.
• Provide 9 kcal per gram.
• An important energy source during rest or low intensity exercise.
• Found in butter, margarine, vegetable oils
• Aka: triglycerides
• Stay solid at room temperature and oils are in liquid form
Family of Lipids
• Triglycerides
• Fatty acids
• Saturated fats
• Monounsaturated fats
• Polyunsaturated fatty acids
• Glycerols
• Phospholipids and Sterols
• Phospholipids
• Lecithin, Cephalin, Plasmologen
• Sterols
• Cholesterol, Ergosterol, Calciferol
Functions: Lipids
• Carries fat-soluble vitamins
• Provides essential fatty acids: linolenic acids and alpha-linolenic acids
• Omega fatty acids help reduce incidence of blood clots and lower
blood cholesterol and plasma triglycerides
• Component of cell structures particularly in the brain and CNS
• Serves to support and cushion vital organs and provides insulation
• Body cells can utilize fatty acids as sources of energy
' Adds flavor to food and satiety value
Food sources
• Visible fats: cooking fats and oils, butter, margarine, fats on meat
• About 1/3 of total dietary fat is invisible fat: lean meat, nuts, eggs,
dairy products, baked goods, fried foods, mayonnaise, avocado
• Cholesterol is only found in foods of animal origin
• Saturated fats: large amounts in fats of animals - beef, prok, lamb,
less in poultry and fish
• Monounsaturated fats: olive oil, canola oil, sunflower oil, chicken fats
and avocado
• Polyunsaturated fats: fruits and vegetables and most plant oils in
.Mflower, soybean and corn oil
RDA: Fats
• It is recommended that approximately saturated,
monounsaturated and polyunsaturated fats should
comprise 10% of the total calories consumed for a
total of 30%
Proteins
• Proteins are chains of amino acids.
• Proteins can supply 4 kcal of energy per gram, but are not a
primary energy source.
• Proteins are an important source of nitrogen
• Amino acids - backbone of proteins
• Contain 16% nitrogen along with sulfur and other elements:
phosphorus, iron and cobalt
• All enzymes, antibodies and most hormones are proteins
Proteins
• Proteins are important for
• Building cells and tissues
• Maintaining bones
• Repairing damage
• Regulating metabolism
• Protein sources include meats, dairy products, seeds, nuts, and
legumes
• RDA: 10-15% of total calories
Vitamins
• Vitamins: organic molecules that assist in regulating body processes.

• Vitamins are micronutrients that do not supply energy to our bodies.

• Fat-soluble vitamins
• Water-soluble vitamins
Vitamins
• Fat-soluble vitamins:
• Vitamins A, D, E and K
• Dissolve easily in fats and oils

• Fat-soluble vitamins can be stored in the body.

Vitamins
• Water-soluble vitamins:
• Vitamin C and the B vitamins
• Remain dissolved in water

• Excess water-soluble vitamins are eliminated by the kidneys and

cannot be stored in our bodies.
Minerals
• Minerals: inorganic substances required for body processes.

• Minerals include sodium, calcium, iron, potassium, and

magnesium.

• Minerals have many different functions such as fluid regulation,

bone structure, muscle movement, and nerve functioning.
Water
• Water is a critical nutrient for health and survival.
• Water is involved in many body processes:
• fluid balance
• nerve impulses
• nutrient transport
• removal of wastes
• chemical reactions
• muscle contractions
The Food System and Nutrition
• The food system refers to a set of processes that involves production,
processing, distribution and use of foods
• Processes in the food system play an important role in the nutritional
and health status of individuals
• Factors related to labor force determine the kind and amount of food
that is available
• Economic, demographic and cultural factors and health nutrition
services determine where and how the food supply is distributed at
the community level.
The Food System and Nutrition
• Any imbalance or deficiency in either food production or distribution or in
both could result to reduced or imbalanced food concumption among the
population or certain segments can also result to malnutrition
• Physiologic differences that increase vulnerability, infection and imbalance
in food consumption can result to malnutrition
• Malnutrition becomes worse with the combined effects of low or
imbalanced food intake and infections, especially among the nutritionally
vulnerable.
• Malnutrition results to low productivity, thus affecting the quality of the
labor force for food production
can also increase or make infection worse.
Food System Model on Multifactorial Causality of Malnutrition by Taylor and Taylor
Key Dimensions in Nutritional Transition
1. Rapid Urbanization
2. Demographic Transition

c Life Economic
Human
Expectancy Development Reforms
W

Sustainable Degenerative
Igvel op m^ Malnutrition Diseases
Emerging Nutritional Re-emerging
Problems Nutritional Problems
1. Diabetes mellitus 1. Tuberculosis
2. Osteoporosis 2. Beri-beri
3. COPD 3. Food Allergy
4. Renal Disease 4. Bronchial Asthma
5. CVD/Hypertension 5. Diarrhea
6. CA - breast and colon
7. Arthritis
8. Anorexia nervosa
9. Obesity
10. mulnuli iliui i___
Emergence of Diseases and Its High Risk
Factors
Model of Determinants of Health
Social Physical Genetic
Environment Environment Environment
Determinants, Support System and

FOOD: A Discrete Variable for Health & Diseases

Goals in Nutritional Management

1.Industrialization
2.Simplification
3.Variation
PROTEIN-ENERGY MALNUTRITION
-Develops in children and adult whose consumption of protein
and energy (as measured by calories) is insufficient to meet
the body's nutritional needs
-Occur in persons who are unable to absorb vital nutrients or
convert them to energy essential for healthy tissue formation
and organ function
-Often seen in elderly patients and poor children
PROTEIN-ENERGY MALNUTRITION
-Reflects combined deficiencies in:

1. PROTEIN - deficit in amino acids needed for cell

structure and function
2. ENERGY - calories derived from macronutrients:
proteins, fats and carbohydrates
3. MICRONUTRIENTS - Vitamin A, B complex, iron, zinc
and others
PROTEIN-ENERGY MALNUTRITION
TYPES:

1. PRIMARY PEM - results from a diet that lacks sufficient sources of

protein and/or energy

2. SECONDARY PEM - usually occurs as a complication of AIDS, cancer,

chronic renal failure, inflammatory bowel disease, and other
illnesses that impair the body's ability to absorb or use nutrients or
compensate for nutrient losses.
STATURE
PROTEIN-ENERGY MALNUTRITION
-Causes of severe PEM
1. Chronic-severely low energy and protein intake
- exclusive breastfeeding for too long
- dilution of formula
- unclean, non-nutritious complementary
foods of low energy and microdensity

2. Infections - measles, diarrhea

3. Xenobiotics - aflatoxins
UNDERNUTRITION UNDER LIFE STAGES

Obstetric Morbidity
Infection/Sepsis
Anemia
Death

Infant/Child: Behavioral Causes:

Infection (Diarrhea, ARI) Related to Breastfeeding,
Poor Growth Complementary Feeding,
Impaired mental, motor HH diet, Low SES, Poor
and behavioral Education
development
Death
The VICIOUS CYCLE of UNDERNUTRITION and INFECTION
 Higher mortality
Inadequate 'mpaired mental
food, heath Older Adults Reduced abiffa rate ji
development
and care Vlalnourishec to care for bab*
Increased risk for adult
chronic diseases

Baby Low Untimely

Inadequate
Birth Weight inadequate
fetal i
weaning
nutriti® Inadequate catch Frequent
up growth infections

nadequate food,
eath and care
malnourished Pregnancy
Low Weigh Chi d Stunted

Reduced
Higher mental
Adolescent
maternal capacity
Stunted
mortality

Inadequate food.

heath and care capacity

Nutritional Deficiencies
•Xerophthalmia •Bleeding tendencies
•Beri-beri •Anemia
•Pellagra •Goiter
•Scurvy •Neural tube defects
•Rickets •Osteoporosis
Malnutrition
• Refers to deficiencies, excesses, or imbalances in a
person's intake of energy and/or nutrients
Forms of Malnutrition
Forms of Undernutrition
1. Wasting (low weight-for-height/length)

2. Stunting (low height/length-for-age)

3. Underweight (low weight-for-age)

4. Micronutrient deficiencies
Wasting
• Indicates recent and severe weight loss

• A person has not had enough food to eat and/or

they have had an infectious disease, such as
diarrhea, which has caused them to lose weight
Stunting
• Result of chronic or recurrent undernutrition
o usually associated with poor socioeconomic conditions, poor maternal
health, and nutrition, frequent illness, and/or inappropriate infant and
young child feeding and care in early life

• Stunting holds children back from reaching their physical and

cognitive potential
Magnitude of the Undernutrition
Problem

• Worldwide

• 52 million children under 5 years old are

wasted
• 17 million are severely wasted
• 155 million are stunted
Causes of Undernutrition

Figure 2 2 Conceptual nants’dffSglThde~rnutnfion

Source: ASEANAJNICEF/WHO (2016)
Consequences of Undernutrition
• Child undernutrition increases the risk of death from
infectious diseases, such as diarrhea, pneumonia and
measles.
• Stunting and wasting cause death of under five children at
14% and 13%, respectively (Black et al., 2013).
• Children with severe wasting have 11.6 times greater risk
of dying compared to non-wasted children and children
with moderate wasting have an approximately three times
greater risk of dying (ASEAN/UNICEF/WHO, 2016).
Consequences of undernutrition
• Children with suboptimal breastfeeding in the first two years also
contribute to a significant proportion (11.6%) of under-five deaths
(Black et al., 2013).
• An infant who is not breastfed is more than 14 times more likely to
die from all causes than infants exclusively fed with breast milk in
the first six months of life (Black et. al., 2008).
• Infants who are exclusively breastfed are 11 times less likely to
die from diarrhea and 15 times less likely to die from pneumonia.
• Initiating breastfeeding within the first hour after birth can reduce
newborn mortality by up to 20% (Edmond et al., 2006; Mullany et
al., 2008)
Micronutrient Supplementation
• the provision of pharmaceutically prepared vitamins and
minerals for treatment or prevention of specific
micronutrient deficiency.
• Importance: Micronutrient deficiencies can easily develop
during an emergency or be made worse if they are already
present.
• Focus: pregnant and lactating women and children aged 6 to
59 months as the groups most vulnerable to micronutrient
deficiencies and their consequences
 Common Micronutrient Supplementation
Activities - Vitamin A
Rationale
Vitamin A supplementation has been shown to
reduce child mortality by 23-34%
It reduces the severity of illness, thus decreasing
childhood mortality. Specifically, vitamin A
supplement
• reduces deaths due to measles by about 50%
• reduces deaths due to diarrhea by about 40%
• reduces illness due to malaria by 30%
Considered one of the most cost-effective public
health measures in improving survival, growth and
development of children at an estimated cost of
Php 40 per healthy life saved.
Helps re-establish body reserves lost due to acute,
chronic or repeated infectious diseases.
Procedures
1. Give additional vitamin A to 6-11-month-old
infants (100,000 I.U.) and 12-59-month-old
children and post-partum women (200,000
I.U.) as well as children with persistent
diarrhea, severe pneumonia and severely
underweight, unless they have received a
similar dose in the past 4 weeks.
2. Children with measles should be given VAC
regardless when the last dose of VAC was
given. Give 1 capsule (100.000IU) upon
diagnosis regardless when the last dose of
Vitamin A capsule (VAC) was given. Give
another capsule after 24 hours.
3. Vitamin A Is prepositioned
 Iron Supplementation
Rationale
Increases hemoglobin concentration
and reduces iron deficiency anemia.
Enhances the cognitive and motor
development of young children.
Increases work performance and
productivity.
Procedures
Elemental iron can be provided in
which dosages depend on age
(Annex 6). Once the micronutrient
powder (MNP) is locally available,
iron requirement will be in the form
of MNP instead of iron drops.
Iron Supplementation is not given
during emergencies
 Iron-folic acid Supplementation
Rationale
Iron-folic acid supplementation prevents neural
tube defects among women of reproductive age
beginning from one month prior to conception
(since the closure of the neural tube is on the
28,n day of gestation, deficiencies must be
corrected before a woman gets pregnant).
Neural tube defects are defects of the brain and
spinal cord.
It lowers the risk of deaths during childbearing
by preventing severe anemia which is highly
associated with severe bleeding.
Procedures
In populations where the prevalence of
anemia among nonpregnant women of
reproductive age is 20% or higher, intermittent
iron and folic acid supplementation is
recommended as a public health intervention
in menstruating women, to improve their
hemoglobin concentrations and iron status
and reduce the risk of anemia
 Zinc supplementation

Rationale Procedures
Zinc supplementation as an addition to the If a child has diarrhea, give
management of diarrhea, such as giving zinc reformulated ORS and zinc. Zinc
in addition to the reformulated ORS (oral supplement should be given for
rehydration solution) has been shown to not less than 10 days.
significantly reduce the duration and severity
of diarrhea compared to ORS alone.
Zinc also decreases the number of episodes
of diarrhea within 2-3 months after the
supplementation regimen
 Micro-Nutrient Powder
Rationale
Multiple micronutrient powder (MNP) is a premix of
vitamins and minerals in powder form which may be
sprinkled once daily into the semi-liquid/soft foods of 6-
23-month-old children and can be extended up to 59
months , without changing the color, taste or texture of
the food. MNP can be extended to pregnant and
lactating women. MNP supplementation is also indicated
in emergencies.
MNP is adequate to rapidly improve iron stores that lead
to increased hemoglobin concentrations . MNP is single­
use 1 gram sachets, packs of 30 sachets per 1 gram
sachet.
Procedures
1. Ensure that 6-23-month-old children receive the
Micronutrient Powder (MNP) supplement.
2. Babies aged 6-11 months need 60 sachets of
MNP while children aged 12-23 months need
120 sachets.
3. MNP can be given starting at 6 months during
the introduction of complementary foods within
the period of 6 months. MNP can be mixed with
soft or semi-solid food before feeding the child.
Do not add MNP to any food before or during
cooking for nutrient retention.
4. If available, expand the provision of MNP to 24-
59-month-old children as well as to pregnant
and lactating women
Dietary Supplementation

• provision of nutritious rations to targeted

individuals that supplement the energy and
nutrients missing from the diet of those with
higher nutritional needs, or those who are
moderately wasted.
KEY Organogram of feeding programs in emergencies

Source Harmonized Training Package on Nutrition m Emergencies

known as dietary supplementation

Acute malnutrition
• Acute malnutrition results from current and severe nutritional
restrictions of an individual.
• results from current and severe nutritional restrictions of an
individual
• due to present illness and inappropriate childcare practices

Weight loss Bilateral pitting edema

Acute malnutrition
• Major risk factor for child mortality

• Affects a total of 5.6% of children under the age of 5 years in the

Philippines (eNNS, 2018)

• Children with SAM are nine times more likely to die than those who
are well nourished.
Acute malnutrition
• Children with MAM do not usually have the evident
changes in metabolism, physiology, and immunological
status that SAM children suffer from.

• The increased risk of MAM children is relatively small

compared to the increased risk of SAM children.
Classifications of Acute malnutrition

•MAM - Moderate acute malnutrition

•SAM - Severe acute malnutrition
•GAM - Global acute malnutrition
>total prevalence of MAM and SAM
^Measurement of NS
Identification of Acute Malnutrition
in infants <6 months of age

SAM MAM
• Presence of • W/L <-2 SD and >-3 SD
bilateral pitting
edema
• W/LC-3SD
Identification of Acute Malnutrition
in children aged 6-59 months
SAM MAM

• MUAC < 115 mm (or < • MUAC < 125mm (<

11.5cm) 12.5cm) and > 115 mm (>
• Presence of bilateral 11.5cm)
pitting edema • W/H or W/L <-2 SD and > -
• Weight-for-Height (W/H) 3SD
or Weight-for-Length
Flow Chart in classifying MUAC screening data
to determine feeding interventions
Nutrition screening at the community,
evacuation centers and health facilities
(MUAC, weight for height z score and
presence of nutritional edema)

Z-score <-2 to -3 Z-score <-3

&absence of
1 MUAC 11.5 cm to
nutritional edema MUAC <11.5cm
<12.5cm
| absence of edema | &/or nutritional edema
r
medical with medical
Targeted dietary complication complication
supplementation
(RHU)
therapeutic In-patient
program therapeutic
program
(hospital)
 Interventions
Interventions for
Management of Targetec Dietary
MAM SuoDlerr entation

Routine Child Health

! prvirps

1
Feeding Assessment Vitamin A
------- and Counseling-------- — Supplementation-----

Micronutrient Powder Iron Supplementation

Supplementation

Vaccination, Dental,
Hygiene,etc..
Nutritional Assessment

the process of collecting, processing, & analyzing &

interpreting information on the nutrition problem
obtained from anthropometric, biochemical, clinical &
dietary methods
NUTRITIONAL ASSESSMENT
Methods:
•Anthropometric
•Biochemical
•Clinical
•Dietary
1. Anthropometric - measurement of variations of the physical
dimension and gross composition of the human body as in weight,
height/length, and mid upper arm circumference taken in the left
arm (left MUAC).

2. Biochemical - measurement of nutrient levels and their metabolites

using biological specimens like blood and urine. Several stages in
development of malnutrition can be identified by laboratory
methods. In both over and under nutrition, tissue stores nutrient
gradually change.
3. Clinical - physical examination of an individual for signs suggestive of
malnutrition such as paleness. Medical history and physical
examinations are clinical methods used to detect symptoms and signs
associated with malnutrition.

4. Dietary - collection of data on food intake. Dietary assessment

method is used to assess the first sign of any nutritional deficiency
(i.e., dietary inadequacy). Dietary information is also useful for
developing food intervention such as food-based dietary guideline.
Anthropometry for children
• Accurate measurement of height and weight is essential. The
results can then be used to evaluate the physical growth of the
child.

• For growth monitoring the data are plotted on growth charts

over a period of time that is enough to calculate growth
velocity, which can then be compared to international
standards
Measurements for adults
1. Height
2. Weight
3. IBW
4. BMI
5. Waist Circumference
6. Waist-Hip Ratio
Measurements for adults
1. Height
2. Weight
3. IBW
4. BMI
5. Waist Circumference
6. Waist-Hip Ratio
 ai

If
Biochemical tests include various blood, urine,
and stool tests.
A deficiency or toxicity can be determined by
laboratory analysis of the samples.
The tests allow detection of malnutrition before
signs appear.
• The following are some of the most commonly used tests
for nutritional evaluation.
• Serum albumin level measures the main protein in the
blood
• used to determine protein status.
• Serum transferrin level indicates iron-carrying protein in
the blood.
• The level will be above normal if iron stores are low and below
normal if the body lacks protein.
Food Frequency Questionnaire

• In this method the subject is given a list of around 100

food items to indicate his or her intake (frequency &

quantity) per day, per week & per month.

• inexpensive, more representative & easy to use.

Another method is the food diary.
•The client is asked to list all food eaten in a 3-4-
day period.
• Neither method is totally accurate because clients
forget or are not always totally truthful.
•They are sometimes inclined to say they have
eaten certain foods because they know they
should have done so.
Stages for the Development of a Nutritional
Deficiency and methods used to assess deficiency

1 Dietary Inadequacy Dietary

2 Decreased level in reserve tissues Biochemical
3 Decreased level in body fluids Biochemical
4 Decreased functional level in tissues Anthropometric/ Biochemical

5 Decreased activity in nutrient-dependent Biochemical

enzyme
6 Functional change Behavioral/ Physiological

7 Clinical symptoms Clinical

8 Anatomical sign Clinical

Nutrition Program Management (NPM)

• A decision-making process of identifying potential nutrition

problems and needs of a specific population group, analyzing
possible ways of preventing and controlling malnutrition,
allocating resources based on needs and expectations, and
taking deliberate action to address nutritional problems,
including those related to monitoring and evaluation (NNC,
2005)
Nutrition Program Management (NPM)
•The Local Nutrition Action Plan (LNAP) is formulated
using the Nutrition Program Management (NPM)
planning cycle.

•The Local Nutrition Committee (LNC) with the

Provincial/City/Municipal Action Officer (P/C/MNAO)
plans and implements nutrition activities, projects, and
4 PHASES OF THE NPM CYCLE

Phase 1:
Planning

r--------------------------------------------

Phase 4: Re­ Phase 2:

planning Implemention
h
Phase 3:
Monitoring and
Evaluation
Figure 31 The Four Phases of the NPM Cycle
Impact Programs
• Home, School and Community Food Production
• Food fortification
• Micronutrient Supplementation
• Nutrition Information, Communication and Education
• Food Assistance
• Livelihood Assistance
• Nutrition in Essential Maternal and Child Health Services
Facilitating/Enabling Activities

•Human Resource Development

•Nutrition Advocacy
•Policy and Standards Formulation
•Research and Development
•Resource Generation and Mobilization
Nutrition Surveillance:
Determining Issues and Concerns
Problem Tree
•a tool for situational analysis
Problem Tree
• traces the chain of factors that can affect the nutrition
situation
• constructed by asking & answering a series of “whys” to
understand the factors which affect nutrition situation

• provides a clearer picture of possibilities for nutrition and

related interventions
Nutrition Intervention
• any policy, program, project or activity
that will contribute to change or improve
nutrition situation
Reduction of underweight and
stunted under-five children
•Support for pregnant and lactating women to practice
optimum IYCF
• Capacity building on IYCF (peer counselor)
•Training of health & nutrition workers on IYCF
counselling
Reduction of underweight and stunted
under-five children

•Setting up & maintaining human milk banks

• Enforcement of EO 51
•Home fortification of complementary foods
through the use of multiple micronutrient
powder
Reduction of wasted under-
five children

•Active identification of cases

•Set up and use of a referral system
•Building capacities of health care
facilities & community
Reduce prevalence of nutritionally-at-
risk pregnant women

•Integration of nutrition services in ante­

natal care services
• Counselling
• Supplementary feeding, when possible
• iron supplementation
Reduce prevalence of thin school-
age children

• Delivery of an integrated package of nutrition

services in the school system
• supplementary feeding (thin)
• nutrition education
• safe drinking water & sanitary toilet facilities
Reduce prevalence of thin school-
age children

• Delivery of an integrated package of nutrition services in

the school system
• Essential Health Care Program
• Growth monitoring and promotion
•Inclusion of modules on nutrition and food
safety & sanitation in ALS
Reduce prevalence of VADD & IDD; & IDA among
infants 6-11 months old, 1-2 years old, pregnant &
lactating women

•Micronutrient supplementation
• Vit A supplementation 2X/year for all <5 y.o
• Vit A supplementation for children w/ measles
• Iron supplementation for pregnant (180 days)
• Iodine supplementation for pregnant
Reduce prevalence of VADD, IDA, IDD

•Food fortification
•Monitoring of mandatory food fortification of
staples
• Monitoring of storage, ports, food
establishment & outlets; point of production
and imported salt
Reduce prevalence of VADD, IDA,
IDD

•Food fortification
•Make iron-fortified rice available in 4Ps areas
• Provision of support to industries
Reduce prevalence of VADD, IDA, IDD

• Promotion of home-based production & consumption of:

• vitamin A- and iron-rich foods with emphasis on animal
sources
• Fortified food
• Fats for Vitamin A
 Reduce prevalence of VADD, IDA, IDD

•Promotion of home-based production &

consumption of vitamin A- & iron-rich foods
Reduce prevalence of VADD, IDA, IDD

• Promotion of home-based production & consumption of:

• vitamin A- and iron-rich foods with emphasis on animal
sources
• Fortified food
• Fats for Vitamin A
• Vitamin C-rich foods for Iron
• & avoid giving coffee & tea for children
 Reduce prevalence of VADD, IDA, IDD

•Promotion of home-based production &

consumption of vitamin A- & iron-rich foods
• Provision of material support
•Quad-media campaign
• Integration of related information in the school
curricula
Reduce prevalence of VADD, IDA, IDD

•Continuing advocacy among

fortified foods producer
•Prevention & management of
related infections
Decreased percentage of households w/
inadequate calorie intake

Increasing food supply through food

production policies & programs
• Pursue appropriate agriculture, agrarian reform & trade
policies & programs to ensure stable supply of key
commodities
• Pursue infrastructure development
Decreased percentage of households w/
inadequate calorie intake

• Increasing food supply through food production

policies & programs
• Stockpiling of basic commodities to ensure food supply
during emergencies
• pursue policies and programs that will stabilize the
prices
Decreased percentage of households w/
inadequate calorie intake

• Increasing food supply through food production

policies & programs
• Increasing investment in agriculture & give farmers
access to:
• Knowledge & innovation
• Assets (land & water)
• Markets
• Credit
Decreased percentage of households w/
inadequate calorie intake

• Improving the economic access to food

• Pursue policies & programs that will

• create an environment conducive to investment that will also
generate sustainable jobs

• develop skills consistent with job market at national & local

levels
Decreased percentage of households w/
inadequate calorie intake

• Improving the economic access to food

• Converge social protection & safety nets in areas

most vulnerable to hunger

Protecting the vulnerable from food insecurity

through food based safety nets
□ Direct distribution of rice
□ Emergency employment
Levels of overweight and obesity among
children and adults do not increase any further

• Promotion of healthy lifestyle in community,

school & workplace
• quad-media campaign on increased consumption of
fruits, veggies & root crops
• Wellness program
 Other Interventions
STRATEGIES
a. Prevention and • Immunization of children
management of • Management of childhood illnesses
infections • Zinc supplementation in the management of
diarrhea
Setting up of safe water supply
Regular deworming of children
Appropriate management of illnesses with
direct link to nutritional deficiencies (e.g.
malaria)
 Other Interventions
STRATEGIES MEASURES/INTERVENTIONS
c. Monitoring of • Provision of tools for measuring
weight and height and weight and determining
height of weight and height status
preschool and • Training on proper measurement
school age and use of information generated
children (for health and nutrition personnel,
elementary school teachers)
 Other Interventions
STRATEGIES MEASURES/INTERVENTIONS
d. Coordination and • Organization/revitalization of local
integration of efforts
for addressing hunger
nutrition committees
and malnutrition • Trainings and related support for
effective local nutrition program
management
• Deployment, training and assessment
of BNSs
 Other Interventions
STRATEGIES MEASURES/INTERVENTIONS
e. Adoption of key • Identification, assessment, advocacy for
nutrition and legislations
related policies at > Milk code
the local levels > Mandatory plantilla positions on nutrition at
local level
> Incentives for community-based nutrition
volunteers
> Funding allocation for nutrition and related
programs
Other Interventions
STRATEGIES MEASURES/INTERVENTIONS
f. Guidelines, • Formulation/adoption of guidelines on:
standards > Operation timbang
formulated for > Growth monitoring and promotion
improved nutrition > Nutrition planning at local levels
action > Nutrition education
> Integration of nutrition in development and sectoral
policies, programs and projects
> Community-based management of acute malnutrition
> Policy on nutrition management in emergencies
Interventions for Nutrition Management
in Emergency & Disaster Situations

• Food rations for mass supplementary

feeding
• Multiple micronutrient powder
• Vitamin and mineral supplementation
"Our food should
BE OUR MEDICINE
AND OUR MEDICINE -
SHOULD BE OUR FOOD
~ Hippocrates