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 Disease Immediate causes

Inadequate access to food

Inadequate care for mothers n children

Insufficient health services n unhealthy environment

Inadequate education
Formal n nonformal institutions Political n ideological superstructure Economic structure Basic causes Underlying causes

Potential resources

The Triple A Cycle

1. Assessment: situation

assessment

analysis

2. 3. 4.

action

5. 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

Height for age Z score Weight for height Z score

< - 2 SD
< - 2 SD < - 2 SD

Underweight
Stunting 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

Inadequate dietary intake

Disease; incidence, severity, duration

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 Disease Immediate causes

Inadequate access to food

Inadequate care for mothers n children

Insufficient health services n unhealthy environment

Inadequate education
Formal n nonformal institutions Political n ideological superstructure Economic structure Basic causes Underlying causes

Potential resources

General guidelines to assist in decisions to implement nutrition program

Malnutrition rate 20% or SERIOUS BLANKET supplementary feeding, supplementary feeding, THERAPEUTIC feeding program ALERT

Malnutrition rate 1519% + aggravating factors

GENERAL RATION < 2100 Kcal/pers/day Malnutrition rate 1015% or Malnutrition rate 5-9% + aggravating factors

TARGETED supplementary feeding, THERAPEUTIC feeding program

ACCEPTABLE

Always improve general rations

Malnutrition rate < 10% with no aggravating factors Taken from Care International

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 14 13 15 17 <15% 15-19.9% >=20% 16 18 31 32 33 35 34 51 52 53
Prev 12.71 17.40 19.12 12.05 18.26 11.84 22.22 23.09 Code 61 62 63 64 71 72 73 74 Province Kalbar Kalteng Kalsel Kaltim Sulut Sulteng Sulsel Sultra Prev Code Province 23.15 81 Maluku 19.54 82 Papua 21.97 18.04 11.86 21.10 20.10 17.18 Prev 15.31 15.59

64 61 62 63 73 74 72

71

81 82

Code 11 12 13 14 15 16 17 18

Province DI Aceh Sumut Sumbar Riau Jambi Sumsel Bengkulu Lampung

Prev 15.18 17.58 19.74 16.28 18.19 15.30 15.10 15.95

Code 31 32 33 34 35 51 52 53

Province DKI-Jkt Jabar Jateng DI Jogja Jatim Bali NTB NTT

Source : Ministry of health, 1999

88

PREVALENCE OF SEVERLY MALNOURISHED AMONG UNDER-FIVES BY PROVINCE, SUSENAS 1999

11 12 14 13 15 17 <5% 5-9.9% >=10% 16 18 31 32 33 35 34 51 52 53
Prev 5.72 6.16 5.42 3.58 7.78 3.98 10.64 10.13 Code 61 62 63 64 71 72 73 74 Province Kalbar Kalteng Kalsel Kaltim Sulut Sulteng Sulsel Sultra Prev code Province 11.48 81 Maluku 7.56 82 Papua 8.23 7.57 8.24 7.23 9.01 5.63 Prev 7.34 9.67

64 61 62 63 73 74 72

71

81 82

Code 11 12 13 14 15 16 17 18

Province DI Aceh Sumut Sumbar Riau Jambi Sumsel Bengkulu Lampung

Prev 10.95 11.36 7.55 8.40 9.69 5.93 9.82 8.46

Code 31 32 33 34 35 51 52 53

Province DKI-Jkt Jabar Jateng DI Jogja Jatim Bali NTB NTT

Source : Ministry of health, 1999

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

Public health Effective magnitude of interventions the problem

100 million children, contributory factor in 3 million childhood deaths annually Single dose supplementati on administered with vaccination

Selected micronutrient deficiencies, consequences, and strategies (2)

Micronutrient Clinical manifestations of deficiency Anemia, poor cognitive development, increased susceptibility to infection Public health magnitude of the problem 2 billion people worldwide, mostly women and children Effective interventions Fortification, administration of supplements and antihookworm treatment

Iron

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
Clinical (primary) Night blindness (XN) Bitots spot (X1B) Corneal xerosis/ulceration/keratomalacia (X2,X3A,X3B) > 1.0 > 0.5 > 0.01

Minimum prevalence (%)

Xerophtalmia-related corneal scar (XS)

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

> 0.05
> 5.0

Summary schedule for high dose vitamin A supplementation of postpartum women and infant/children in vitamin A deficient areas
At birth 6 weeks 10 weeks 14 weeks 9 months (or any time between 6 and 11 months 100.000 IU 12-59 months

Mother Infant/child

200.000 IU* 50.000 IU 50.000 IU 50.000 IU 200.000 IU every 46 months

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

Prevalence goal

< 1%

Biochemical indicators
Serum retinol 0.70 mol/l or Breast milk retinol 1.05 mol/l or 8 g/g milk fat < 5% < 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
Severe Iodine deficiency Moderate Iodine deficiency

Median urinary iodine concentration (g/l)

<20 20-49

Mild Iodine deficiency

Ideal Iodine intake More than adequate iodine intake; may pose increased risk of iodine-induced hyperthyroidism Excessive iodine intake

50-99
100-200 201-299

>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
Under-fives, 0-59 months School children, 6-12 years Children > 12 years and adults Pregnant and lactating women

Intake (g/day)
90 120 150 200

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 14 13 15 17 61 62 72 81 82 64 71

16
18 31 32 33 35 34

63

73 74

Keterangan
< 5 % 5 - 19.9 % 20-29.9 % > 30 %

51

52 53

11 12 13 14 15 16 17 18

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 Jawa Barat Jawa Tengah Yogyakarta Jawa Timur Bali Nusa Tenggara Barat Nusa Tenggara Timur Timor Timur

2.0% 4.5% 4.4% 6.1% 1 6.3% 12.0% 19.7% 38.1% 21.4%

61 62 63 64 71 72 73 74

Kalimatan Barat Kalimatan Tengah Kalimatan Selatan Kalimatan Timur Sulawesi Utara Sulawesi Tengah Sulawesi Selatan Sulawesi Tenggara

2.3% 8.1% 1.7% 3.1% 3.0% 16.5% 10.1% 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 Children 6 months to 5 years Children 5-11 years Children 12-13 years Non-pregnant women Pregnant women Men Hb below (g/dl) 11 11.5 12 12 11 13 Ht below (%) 33 34 36 36 33 39

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

Stages of iron depletion

Stage I

Decrease in iron stores

Feritin

Stage II

Biochemical Indicators of low Iron stores

Transferrin saturation Erythrocyte protoporphyrin

Stage III

IDA

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