NUTRITION, HEALTH, DISEASES

Darmono SS
 NUTRITION, HEALTH, DISEASES
• The study of life science interaction
Health perspective
 5 D : death,
diseases,
disability,
 discomfort,
destitution
 Pathogenesis nomenclatur
• Window opportunity
• Long lasting impact
• Evidence based
• Lengthy exposure
• Susceptible
• Dose dependent
• Cut off point
 Pathogenesis
• Temporality :
• It is desirable  the exposure  to procede
the onset of diseases
• The extent to which nutrition factor may
influence either onset or progession of
diseases
• Nutrition should assessed before the diseases
is diagnosed
 Pathogenesis
• The diseases of long latency processed
• The nutrition usually already present and
progressing at the time NUTRIENT is assessed
• This is done in part because dietary intake
after the diseases is established may not
provide the appropriateness exposure
information
• Patogenesis attempt  time period precede
 Riskesdas 2008, 2010
• Life expectancy Indonesia 63 & 67 th
• Japan, North Europe, Mediteranian countries ?
• Indonesia’ problems  Double burden 
deficiency & over nutrition
• Stroke  leading cause of death (2007)
• CVD  second leading cause of death (1993) -
2007
• Carcinoma is also leading cause of death
• Kariadi hospital : 52 % bor of diseases
 Evidence based medicine
• USA USA Hanes
• Framingham study  academic paper,
epidemiology
• Increasing Degeneratif diseases world wide,
obesity, DM, hypertension, cancer, COPD,
• Health prevention  cost, management
• Health promotion -> cummunity participation
 NUTRITION, HEALTH, DISEASES
• Food : Visual product, consistency, content, quality,
appeal, smell, taste, texture which interact of with
senses, “Gengsi” ?
• Basic biochemistry of food (nutrients) not only
elucidating the compositions of raw materials and
end product, but also with the changes which occur
in food during its production, processing, storage ,
cooking, distribution, intake.
Erric Blume, 1976
Health - system
NTD, In born error,

Genetic
Health
Policy Healthy
Pupolation
Kebijakan mayoritas
Publik Environm Penduduk hidup
Health
ent HEALTH dalam:lingkungan
Services
yang sehat,
STATUS
Berperilaku hidup sehat,
Healthy Terjangkau oleh
population yankes
Surveylanc yang bermutu
Life Style e, secara adil dan
Nutrition merata
HS Policy
Stroke, CVD, hypertension, DM
tipe 2 , COPD,
 NUTRITION, HEALTH, DISEASES
• Biochemistry of foods are highly complex
nature of food results in a multitude of
desired and undesired reactions with the
controller by variety of parameters.
• Compositions analyses, compound detection,
isolation and structural characterisation of
process optimizing food constituents
 NUTRITION, HEALTH, DISEASES
• Eating related : volume, energy, macro & micro
nutrient,
• Behavior : style, cultures
• Aroma, fiber, refined macro nutrient, trans FA
• Digestibiity, absorption, excretion, (gaster, acid –
based, hormonal, enzyme)
• Do nutrient intake related to energy expenditure?
• Exercise (glucose up take, ATP, ADP, glycogen, blood
glucose, Free fatty acid, lipid deposit etc ?
 NUTRITION, HEALTH, DISEASES
• Country diseases
• Health system  concept
• Health management, cost effectivity,
efficiency
• New paradigma of epidemiology (Barker
hypothesis)
• Health management  prevention,
promotion, health protection,
 NUTRITION, HEALTH, DISEASES
• Drink are several materials : (end product) 
hypertonic, water, electrolit, minerals, vitamins,
etc… are, naturals, processed form related to acid
balances, energy, volume (ISWL + requirement to
maintenance of rehydration & health).
• Drink related to daily consumptions  economic
purposes ?. Is it ?
• Selling product, bussiness perspective, target
marketing, beverage, motivational costruct.
• Problems in USA due to community image 
patology ?
 NUTRITION, HEALTH, DISEASES
• Nutrition has played a significant role in our
world life
• Nutrition has significant role before ONE life
 before birth
• Nutrition has continue affect of in major way
of life  depending on the food and drink you
select
• You are what you eat.
 Case-control study

Exposure Disease
?
?

Prospective cohort study

Exposure Disease
?
?

Retrospective cohort study

Exposure Disease

?
?

= Present
= Absent
? = To be determined

= Investigator at beginning study

Timing of case-control, prospective cohort, and retrospective studies

in relation to exposue and outcome
 Nutrition, health and diseases
• Nutrition icon
• Nutrition guide, 4 sehat 5 sempurna ?  < 1970
• Nutrition balancee as guide for health, 
diseases prevention
• Nutrition education ?
• Requirement Dietary Aallowance  pathology ?
• Pathology and pathogenesis of nutrient intake
 NUTRITION, HEALTH, DISEASES
• Every day  several times a day make you
influence your body’s health for better or, and
worse
• Nutrition  may benefit or harm
• Nutrition  close attention to good eating
habits  bringing health benefit later
• Conversely, carelessness  choice 
contribute to many chronic diseases 
evidence based and epidemiology aspect
 NUTRITION, HEALTH, DISEASES
• In general  a chronic diseases progress
slowly or with litle change and long lasting
impact
• Nutrition : science of the nutrients and other
substances their contain and their action
within the body  intake, ingestion,
absorption, transport, metabolisme,
utilization and excretion  within in organ
NUTRITION, HEALTH, DISEASES ?
• Personal preference
• Habit, intake, patern, culture
• Ethnic, heritage, tradition
• Social interactions, companionship, peer
desires, pressure, hospitality
• Availability, convenience, economy
perspective, accessible, quick system,
• Emotional comfort and values
 NUTRITION, HEALTH, DISEASES
• Long process  long course
 time perspective  Framingham Study, Barker
hypothesis
• Integrative activity during life time
 dynamics
 long lasting impact
 Pathophysiology, pathobiology
 Diseases occurrence
 Evidence based
 NUTRITION, HEALTH, DISEASES
• Food and drink are chemistry substances,
nutrients, materials which, in their naturally
occuring, important properties, “value”,
processed or cooked form, are consumed by
humans as nourhishment for metabolism,
nutrient (protein) synthesis, energy,
maintenance of health, messanger, neuro
transmitter, immunomodulator and
preventing of diseases.
 Nutrition, health and diseases ?
Stroke,
Alzeimer , senile, atrophy

Carotit intima, jugulary

COPDl, Carner pulmonum
CVD, Congestive HD,
Cardiopulmonal, trombo em

Gastro intestinal
Stomac, pancratic,, Ca

Colon, micro flora

Prostate, hypertrophy, Ca
Myoma uteri,, Poly cystic ovarii
syndrome
Ostero porrosis

Gout,
Genu

Musculo skeletal
 Food intake  Eating, “value”
• Food preference ?
• Food falaces ?
• Price ?
• Mood ?
• Environmental
• Availability ?
• Serving standard?
• “Keterpaksaan”
 HEALTH CONDITION, NUTRITION

Life expectancy

Health

Prosperity
Healthy People
Immunity
Tobacco
Physical inactivity
Communicable Diseases
H&S
Dyslipidemia
Risk People Non Communicable Diseases
Environmental
Personality
Behavior - Social
Sick People, chronically emergency, Improper Nutrition
28 % complicated

Disability
Sick People, Dying Indignity
home care
 Health, Nutrition Problems in Life Cycle 12 million
2001 – 2008 (Indonesia) 5 million
IDA
Elderly people

4,5 million
Pregnant
- 3 mill IDA mothers
- 1,5 mill CEM
118 million

10 million

4 million Adolescent girls

& young women

New born
babies 18 million 31 million
- 5 mill malnourished
- 3,5 mill adolescent
- 8,1 million IDA
(15-19 yr) &
- 10 million VAD
School age reprodage IDA
350.000 LBW sub clinic
children - 30 million CEM
Every years

Under five - 11 million stunting

children - 10 million IDA
- 3,4 million IDD risk

Source: WHO MOD, 2008

 TRANSITION OF EPIDEMIOLOGY IN INDONESIA

Others

Injury

Maternal
Perinatal

Vascular
Death

Renal

COPD

Neoplasma
Infection

Household Health Survey

Source: MOH,D 2007
Food intake  pathology Eating “value”
• Emotional sensing
• Place
• Cooking instrument
• Cooking processes
• Food distribution
• Bacteriologis
• Chemist
• Economics
 Problems  pathology study
• Nutrition and diseases is  two side of coin 
vice versa ?
• Foods ?, habit, saturated fat, fibre intake,
• Drinks ? Hypertonic,
• Knowledge ?, awareness ?
• Attitude ?, intake, habit, pattern
• Practices ?, sedentary,
• Environment ?, availability,
• Inborn error ? Neural tube defect
 Pathologi
• Food intake : sources, content, quantities,
qualities, polution,
• Knowledge : food chioce, food falaces,
• Attitude : availability, peer desire, environment
• Culture : japan, meditarian, French paradox,
modern life , labor saving devices, total energy
intake
• Country : Wales (UK)  1980 – 1990  preterm
death  patology ?
• policy, Nutrition icon,
 Nutrition and degenerative diseases
Heart diseases Factor s associated, Risk Possible atributable
associated
Heart diseases Saturated fat Cholesterol Mono sacharide, poly
excess, sodium intake, unsaturated, omega 3,
abdominal fat, excercise, poly phenol, anti oxidant,
LDL, HDL, folic acid
Cancer Calories excess, nitrite selenium, anti oxidant,
preservation, fibre , folic acid,
alcohol, intake(GI, pulmo
(oxidative stress, gaster,
COPD Air trapping, oxidative anti oxidant
stress,
Insulin resistence Obese, pancreatic islet , Exercice
CKD, over feeding,
Stroke Blood viscousity, trombus
hypertension
 Nutrition and degenerative diseases
Alzheimer Brain blood supply, Puly unsaturated fat
Tunica intima intake, mono unsaturated
atherosclerosis fat intake,

Hypertension Renal diseases, poly Hydration, hypertonic

cystic fibrosis, Na intake excess

Osteoporosis Bone density Calcium balance intake

Gout Hyper uricemia, Tubular Renal excretion

Inflamation, saturation
 Total
Jan July Jan July Jan July Jan July Jan July Jan time
1976 1976 1977 1977 1978 1978 1979 1979 1980 1980 2007 at risk

2.0
Subject A
3.0
Subject B x

Subject C 5.0

Subject D 4.0

Subject E x 2.5

Total years at risk 16.5

= Initation of follow up
= Time followed
x = Development of disease

Calculation of person-years for incidence density

 Pathogenesis testing

Ecologic Case control Prospective Randomized

Conclusion and
studies studies studies controlled trials recommendation

The classic sequence of hypothesis testing in nutritional epidemiology leading to diseases prevention
 Estimated Intake

True Intake

Absorbed amounts

Reported nutrient intake

Altered metabolism Disease

Risk factor change

Preclinical disease

The black box approach to the study of diet and disease in nutritional epidemiology
(Pathofisiology occurance )
 ROLE OF EPIDEMIOLOGY AND PATHOGENESIS OCCURACE

Randomized,
controlled
trials

Prospective Conclusion and

studies recommendations
Case-control
studies

Ecologic
studies

The currently practiced sequenced of hypothesis in nutritional epidemiology leading to the diseases
prevention
Nutrition, Health and diseases

Risiko

Your Position ?
Nutrition, Health and diseases

Risiko

Your Position ?
 Health services system (paradigma sehat)
Ilness prevention & environmental
protection,
-Health bariers
-Health & Nutrition
screening
Safety, -Health training
protection -Specific protection
- Health Vulnerable Curative
hazardous group 15 – 21%
illness SDKI,
- Sanitation 2004
- concept of
health Rehabilitative
-Minor illness
-dearhoea
Health -Infections
promotion -Injury
- Health maintenance
- Health & Nutrition
awarness
 Nutrients from Food  can be assigned to four
functional categories :

(1) Those that primarily provide us with energy

(kilocalories [kcal]) C (calorie=kilocalorie)
(2) Those that are important for growth and
development (and later maintenance)
(3) Those that act to keep body functions running
smoothly.
(4) Preventing diseases
Some overlap exists among these groupings. The
energy-yielding nutrients make up a major portion
of most foods.
PROVIDE ENERGY PROMOTE GROWTH REGULATE BODY
AND DEVELOPMENT PROCESS

Carbohydrates Proteins Proteins

Proteins Lipids Lipids
Lipids (fats & oils) Vitamins Vitamins
Alcohol ? Minerals Minerals
Water
Water
 Nutrition, Health and Diseases
• Angel’s Law  economic  nutrition, health
and diseases
• Modernitation ?
• Wasternitation ?
• Bilogic plausibility ?
• Dose resonce relationship of nutrient?
• Strength association ?
• Consistency of association
 Nutrition, Health and Diseases
• Temporally correct of association
• Specificity of association
• Pathogenesis occurnce:
• Evidence based
• Causal inference
• Hill creteria ?  the supposition behind the
creterion  the larger the size of RR or OR 
the more likely the association is to be causal
 Nutrition, Health and Diseases
• The sronger an association is, the less likely it
is to be explanined by other confounding
variables
• Evidence based medicine  multi centre
study in multi years
• Multicolinearity  in analytic approach,
nutrition to be highly correlated
• Can be single nutrient or other nutrient
involved ?
Cohort, 15 tahun, multi stage, random sampling, sampel 169.871, di 30
propinsi, di negara RRC.
Figure 5. Age-Standardized Mortality for the Five Leading Causes of Death from Vascular
Disease (Panel A) and Malignant Neoplasms (Panel B) among 169,871 Study Participants.
Chronic pulmonary heart disease (cor pulmonale) is an abnormality of right ventricular
structure or function, which in China is usuallly caused by chronic obstructive pulmonary
disease. ). (N Eng J Med, 353, 2005).
 Women
Women’s cause
cause of death
of death Men's cause of death

7% Ca 7% Ca

CVD 30% CVD

50%
43%
Pulmonary 63% Pulmonary
diseases diseases

Cohort study di Korea Selatan selama 12 tahun, dg sampel 1.213.829,

umur 30 – 95 tahun hubungannya dengan kematian (Jee SH et all, N. Engl
J Med, 2006)
 Nutrition pathogenesis
• More than human nutrition, biochemistry,
biomarker ....
• Top of the top ?  hulu ?
• Hilir ?
• Community based >
• Community diseases ?
• Hospital based ?
• Waste ?
• ....  emergency ?
 Estimated Intake

True Intake

Altered cholesterol
metabolism

High reported intakes of

saturate fatty acids and Serum total and LDL- Coronary
cholesterol concentrations
cholesterol hearth disease

Atherosclerosis

Preclinical disease

The black box paradigm for studying the diet-heart disease hypothesis