1. Dr. Dalia El-Shafei
Assoc. prof., Community Medicine Department, Zagazig University
http://www.slideshare.net/daliaelshafei

2. LEARNING OBJECTIVES:
Identify sources, functions, effect of deficiency of nutrients.
Understand the characteristics of adequate, balanced diet.
Develop a diet plan by using the dietary guides and nutritional pyramid.
Describe diets for vulnerable groups.
Understand the causes, manifestations and control of malnutrition problems.
Explain methods of assessment of nutritional status.
Describe diet plans for selected chronic diseases (therapeutic diet).

3. FACTORS AFFECTING ENERGY
REQUIREMENTS

4. FACTORS AFFECTING ENERGY REQUIREMENTS
Physical activity
• Type & duration of activity and
size of the person.
Lean body mass (LBM)
• ↑LBM →↑Metabolic activity
→↑Energy requirements.
Age
• ↑BMR & energy requirements
during periods of growth then ↓ at
older age.
Climate
• ↑Energy requirements in low
atmospheric temperature to
maintain body temperature.
Fevers
• ↑BMR by 7% for each ↑0.83°C in
body temperature.
Pregnancy & lactation
• ↑BMR & energy requirements.

5. ESTIMATION OF ENERGY REQUIREMENTS
BMR
• 1.0 K.cal/kg BW
/h (for men)
• 0.9 K.cal/ kg BW
/h (for women)
• BMR/day = 1.0 or
0.9 x BW x 24
Physical activity
requirements
• Sedentary life =
20% of BMR
• Very light activity
= 30% of BMR
• Moderate activity
= 40% of BMR
• Heavy activity =
50% of BMR
Specific dynamic
action of food
(S.D.F)
• Energy needed for
digestion
absorption &
metabolism of
food) = 10% of
BMR.
Energy requirements = BMR + Phys. Activity + S.D.F.

6. THE GLYCEMIC INDEX AND
GLYCEMIC LOAD

7.  A serving of a high-fiber food, such as backed beans
results in lower blood glucose levels compared to the
size serving of mashed potatoes which results in a
higher blood glucose level.
 Why are we concerned with the effects of various foods
on blood glucose? Foods that result in a high blood
glucose level elicit a large release of insulin from the
pancreas which chronically will lead to many bad
effects on the body.

8. Two food measurements have been developed which are
useful in predicting the blood sugar response to various
foods and in diet planning to avoid hyperglycemia.

9. GLYCEMIC INDEX (GI)
It is a measure of how quickly foods that contain
carbohydrate raise blood glucose levels.
Some foods cause a rapid rise in blood glucose (with a high
GI) while others cause a gradual rise (with a low GI).
This depends on starch structure, fiber content, food
processing and other food contents as fat.

12. GLYCEMIC LOAD (GL)
• Another way of describing how different foods affect
blood glucose levels
• More useful because it considers the glycemic index &
the amount of carbohydrate consumed.
Glycemic load = Glycemic index X Grams of CHO serving /100

14. RANGE OF GLYCEMIC INDEX AND GLYCEMIC LOAD:

15. ADEQUATE DIET

16. A mixture of food stuffs selected to satisfy the nutritional
requirements of the body in quality and quantity.
It should be safe and of good taste and smell.
It should be suitable for weather age, effort and
physiological status of everyone.

17. DIETARY GUIDELINES
Every day, food must contain all nutritional elements (all levels
of the guide pyramid).
Eat nutritionally adequate food “Variety of foods; 20% of total
calories from proteins, 25% from fats & the rest from
carbohydrates (55%)”.
Drink plenty of water.
Don't eat between meals (snacking only by fruits & vegetables).
Eat 5-6 small meals instead of 3 huge meals & last-meal must
be before 9 PM.

18. DIETARY GUIDELINES
↓ Salt & refined sugars intake (white poisons).
↓ Intake of canned, preserved, smoked and salted foods.
Check for expired dates for canned & frozen foods and do not
eat nuts stored for long periods (contain aflatoxin).
↑ Consumption of fresh fruits & green leafy vegetables.
↓ Intake of ready-made foods (fast foods) and too much
processed foods “full of saturated fats & cholesterol”.

19. DIETARY GUIDELINES
↑ Consumption of dietary fibers & complex
carbohydrate (whole grain bread).
↑ Consumption of calcium containing foods
(green leafy vegetable, fish with bones and milk).
↓ Consumption of total fats especially saturated
fats and cholesterol containing foods.
Use vegetable oils instead of margarine (trans-
fats) for cooking

20. THE HEALTHY EATING PLATE

21. In (2011) the Nutritional Guide Pyramid was replaced with a new
and simpler icon, My Plate. It is based on how our food, drink, and
activity choices affect our health.

22. Make most of your meal
vegetables & fruits – ½ of
your plate:
• Aim for color and variety
• Potatoes don’t count as vegetables
because of their negative impact on
blood sugar”.
Go for whole grains – ¼ of
your plate:
• Whole and intact grains—whole
wheat, barley, oats, brown rice, and
foods made with them,
• Milder effect on blood sugar &
insulin than refined grains.
Protein power – ¼ of your
plate:
• Fish, chicken, beans, and nuts.
• Limit red meat and avoid processed
meats such as hamburger and
sausage.
Healthy plant oils – in
moderation:
• Healthy vegetable oils like olive,
canola, soy, corn, sunflower, peanut
• Avoid partially hydrogenated oils
“contain unhealthy trans fats”.
• Low-fat does Not mean “healthy.”
Drink water, coffee, or tea:
• Skip sugary drinks
• Limit milk & dairy products to 1-2
servings per day
• Limit juice to a small glass per day.
Stay active:
• The red figure running across the
Healthy Eating Plate’s placemat is a
reminder that staying active is also
important in weight control.

24. ARE THE RELATIVE SIZES OF THE HEALTHY EATING PLATE
SECTIONS BASED ON CALORIES OR VOLUME?
The Healthy Eating Plate does not define a certain number of calories or servings
per day from each food group.
The relative section sizes suggest approximate relative proportions of each of
the food groups to include on a healthy plate.
They are not based on specific calorie amounts, and they are not meant to
prescribe a certain number of calories or servings per day, since individuals’
calorie and nutrient needs vary based on age, gender, body size, and level of
activity.

25. NUTRITION OF VULNERABLE
GROUPS

26. Nutrition plays a major role throughout each stage of the life cycle.
There are nutritionally vulnerable groups who are at risk due to
increased physiological needs to certain nutrients.
Infants &
preschool
children.
School
children.
Adolescents. Pregnant(s)
&
lactating(s).
Elderly
group.

27. NUTRITIONAL DAILY, REQUIREMENTS OF VULNERABLE
GROUPS
Nutrient Infants Adolescents Pregnant Lactating Elderly
Energy 110 kcal/kgm 3600 kcal (boys)
2600 kcal (girls)
2800 kcal 3200 kcal 1800 kcal
Protein 2-3 gm/kg 1 gm/kg 2-3 gm/kg 3 gm/kg 1 gm/kg
Vit. A 375 µgm 1000 µgm 800 µgm 1300 µgm 800 µgm
Vit. D 10 µgm 10 µgm 10 µgm 10 µgm 10 µgm
Vit. C 30 mg 60 mg 70 mg 95 mg 60 mg
Calcium 240 mg 1300 mg 1200 mg 1200 mg 1200 mg
Iron 8 mg 15 mg 30 mg 15 mg 10 mg
Iodine 50 µgm 150 µgm 175 µgm 200 µgm 150 µgm
Zinc 5 mg 15 mg 15 mg 19 mg 15 mg
Folic acid 30 µg 200 µg 400 µg 280 µg 180 µg

28. FEEDING OF INFANTS “BREAST FEEDING”
Advantages of breast milk
• Secreted in the first 3-4 days in small amount.
• High contents of carotene, maternal antibodies, digestible proteins, less sugar and fat and
more sodium, potassium and chloride.
Colostrum
• Rich in proteins, vitamins, mineral, IgA and galactolipid (for brain growth).
• Contains hormones, growth factors & anti-bacterial factors as lysozymes, macrophages.
• Contains lactoferrin which binds iron for absorption and prevents bacterial multiplication.
• It is bacteriologically safe, ready made, sterile always fresh and of suitable temperature.
• Its amount regulated by baby suckling according to his need.
• It reduces risk of infections, allergy and obesity of infants.
Mature breast milk

29. Advantages of breast-feeding process
Has good psychological
effect on baby & mother and
initiating early mother baby
bonding.
Promotes development of
jaws, teeth and speech
pattern of baby.
Helps uterine involution.
↓ Risk of post partum
hemorrhage.
↓ Risk of cancer breast &
ovarian cancer.
Easier for mother and saves
her money that paid in bottle
feeding.

30. Requirements of breast feeding
After birth
• Start as early as possible to stimulate milk
secretion.
1st 6 months • Exclusive "No other food”.
After 6th month
• Weaning started by introduction of other foods
with breast milk
• To face the rapid growth & development of baby
and compensate some deficient nutrients in milk
as iron.
• Start is with fluids, semisolid and solid foods.
• Use spoon or cup not bottle before breast
feeding.
• If diarrhea occurs, stop this food and replace by
another gradually.

31. FEEDING OF PREGNANT & LACTATING MOTHERS
They need more nutritional elements because of:
Growth of the
fetus &
placenta.
↑ Mother
weight.
↑ BMR. Production of
milk.

32. FEEDING OF PRESCHOOL & SCHOOL CHILDREN
Characterized by
rapid growth &
development.
↑ Need of food rich
in proteins, calcium,
iron, vit.D, vita.C,
vit.B complex and
calories.

33. FEEDING OF ADOLESCENTS
During adolescence
period body mass ↑
by 35% in boys &
20% in girls.
Dramatic physical,
biochemical and
emotional changes.

34. FEEDING OF THE ELDERLY
↓ Requirements of all nutrients
due to ↓ BMR, & ↓ activities.

35. ASSESSMENT OF THE
NUTRITIONAL STATUS

36. Methods of Nutritional Assessment
Relevant data
Food data
Availability
Prices
Production
Importation
Vital indices
Morbidity rates
Mortality rates
Investigation of the nutritional status
National food
consumption
Dietary survey Health appraisal
Dietary history
Medical history
24-hours recall
Clinical
examination
Anthropometric
measurements
Weight & height
Skin fold
thickness
Mid-upper arm
circumference
Waist
circumference
Laboratory
investigations
Blood Hg
Serum or urine
Stool analysis
Physiological
tests

37. Food data
Availability Prices Production Importation
Vital indices
Morbidity
rates
Diarrheal
diseases among
children
L.B.W.
Parasitic
infestations
T.B.
Mortality rates
Stillbirth
Perinatal
mortality
Neonatal
mortality
Infant &
preschool
mortality rates
Relevant data

38. National food
consumption
Dietary survey Health appraisal
Dietary
history
Medical
history
24-hours
recall
Clinical
examination
Anthropometric
measurements
Weight &
height
Skin fold
thickness
Mid-upper
arm
circumference
Waist
circumference
Laboratory
investigations
Blood Hg
Serum or
urine
Stool analysis
Physiological
tests
Investigation of the
nutritional status

39. NATIONAL FOOD CONSUMPTION
For estimation of the average food consumption (the
national diet) the food-balance sheet technique is used.

41. Food balance sheet technique
Aim
• Determining the individual share from different foods assuming
that the available foods are distributed equally among the
population.
• It is used for the community as a whole
Steps
• The different foods are divided into “11” similar groups as
cereals, starchy roots, pulses and legumes, sugar and honey, fresh
vegetables, fruits, meat and poultry …etc.
• Calculation of local production of these food groups plus the
amount of foods imported or donated.
• From the above calculation a subtraction of the amount of food
exported plus that not used by human beings (not-edible) is done.
• The difference is called the “Balance” which is the amount
consumed by the population. It is then divided by No. of
population and by 360 to get the individual share in grams from
the national foods per day.

42. The consumption of different
food items as milk, meat, eggs
….etc are analyzed into their
nutrients and energy to give the
individual consumption of
each nutrient (as protein, fats,
vitamins, iron …etc) and
energy per day.

43. Advantages
• Explores the national food
consumption & the main defects
in it.
• Used to compare between average
food consumption in successive
years to show the trend of
consumption.
• Used to compare between different
countries.
• By using it, we can identify the
main sources of different
nutrients in the national diet as
protein & iron contents in Egyptian
diet are mainly from plant sources.
Disadvantages
• Assumes that the food is
distributed equally throughout the
year among the population which is
not true due to different socio-
economic conditions and seasons.
• Ignores differences in
requirements of people regarding
age, sex, occupation, physical
activity …etc.

44. Pattern
of
food
consumption
in
Egypt
Cereals (especially bread) & legumes form the main bulk of diet.
“Supply the greater part of energy, proteins, iron, vit. B & fibres”
Energy is in excess than required (high carbohydrates & fats).
The protein content is mainly from the plant sources (low
biological value).
Moderate consumption of vegetables & fruits.
Low consumption of meat, milk & eggs.
Iron intake is high but mainly from plant sources (cereals) which
is of low absorbability.

45. Impact on nutritional status of Egyptians
Iron & B12
deficiency anemias
Protein deficiency
among children
Obesity

46. DIETARY SURVEY
• Carried out to find out if the food intake satisfies the individuals’
requirements.
• Can be done on individuals or homogenous groups (families, camps,
patients in a hospital) provided that these groups of population eat from
a common kitchen. It is more precise and feasible.
• All foods used in preparing meals are weighing every day with
subtracting the unused parts and wastes. The actual amount of food
which eaten/day are calculated for a special period (one week) then
the end amount divided/No. of individuals in the group/No. of days
(7) to get the actual individual share in food consumption/day.
The method

47. Limitations
• Concerned with what
people are eating which
considered a private
issue.
• Its occurrence by itself
might involuntarily
change the pattern of
food consumption.
Advantages
• More accurate &
feasible (represents the
food actually eaten).
• Suitable for nutritional
experimentation e.g., to
test variations in diet or
the effect of introduction
of new foods.

48. HEALTH APPRAISAL (COMPREHENSIVE CLINICAL
EXAMINATION)
Health
appraisal
Dietary
history
Medical
history
24-hours
recall
Clinical
examination

49. Dietary
history
• Comprehensive nutritional interview
to detect living conditions, habits, culture
and economic & psychological factors ...
etc.
Medical
history
• Malnutrition, parasitic & chronic
diseases.
24-hours
recall
• Simple & cheap method “Recall of all
foods consumed the previous day to the
test but it is not suitable for old
persons”.

50. HEALTH APPRAISAL
(COMPREHENSIVE CLINICAL EXAMINATION)
It is done to detect physical signs of nutritional deficiency.
However, this will be somewhat late as against every case
showing frank clinical manifestations at least there are
“10” cases in the subclinical (biochemical or functional)
stages.

51. Defect in body functions and frank manifestations of malnutrition
Detected by clinical examination and anthropometric measurements.
↓Enzymatic activity and physiological functions
Detected by biochemical and physiological testing
↓Plasma levels of some nutrients
Detected by biochemical testing
↓Food intake or ↑loss
Detected by dietary history, survey.
Effect of nutritional deficiency passes into stages:

52. Skin, hair & nails
• To detect manifestations of vit. A,
B1, B3 & protein deficiencies
Head & neck
• To detect signs of iron, Ca,
iodine, vit.B2, C & fluorine
deficiencies.
Muscles & skeletal system
• To detect P.E.M. & rickets
manifestations.
Nervous system
• To detect signs of vit. B1, B3,
B12 & Ca deficiencies.
Cardiovascular system
• To detect vit. B1 deficiency.

53. Clinical signs & symptoms are not often specific.
Body can adapt to very low intake especially with
sufficient body stores.
Clinical signs take long period to be manifested
“young women having deficient intake of Ca & vita.D
often suffers no ill effects in young age, but they face ↑
risk of osteoporosis after many years”.
Limitations of clinical examination method:

54. Anthropometric measurements
Weight &
height
Skin fold
thickness
Mid-upper
arm
circumference
Waist
circumference

55. Weight & height
They are used mainly
to evaluate nutritional
status of children.
Each of them is
plotted on growth
charts against age for
growth monitoring.

56. Height for age
• <5th percentile of the
reference population
→ Stunted child
(short for age) in
chronic under-
nutrition.
Weight for height
• <5th percentile of
the reference
population →
Wasted child (thin
for age) in acute
under-nutrition.
Weight for age
• <5th percentile of the
reference population
→Underweight child
for age in both acute
& chronic under-
nutrition.
WHO indices for growth monitoring of children:

58. Preschool
children
in Egypt
Stunted
Wasted
Under-weight

59. Body Mass Index (BMI)(Quetelet's index):
Good measure of overweight not obesity as weight may increase due to
excess muscularity or oedema not always due to excess fat deposition.

60. Skin fold thickness (S.F.T.)
Skin thickness over mid-
triceps or mid biceps
muscles or subscapular
or suprailiac regions are
measured by certain
caliber in millimeters.
It is used in infants &
children to assess obesity
(fat deposition).

62. Mid-upper arm circumference (MUAC)
Measuring the circumference of mid-non dominant upper arm by
using non-stretchable tape.
Readings are measured in centimeters and compared with standard
reference tables.
It provides a good measure of the subcutaneous fat reserve as S.F.T.

64. Waist circumference
Should not exceed 88cm for females & 102 cm for males.
Waist hip ratio (WHR): Should be <1, if above denotes android obesity.

65. Laboratory
investigations Blood Hg Detection of iron
deficiency anemia
Serum or urine
Assess the level of the different nutrients
“amino acids, serum retinol, iodine,
some vitamins & alkaline phosphatase
enzyme level to diagnose vit. D
deficiency”
Stool analysis Intestinal parasites
Physiological
tests
Dark adaptation test &
muscle activity test

66. THESE METHODS OF ASSESSMENT CAN BE USED:
On the community level
• National food consumption
method.
• Dietary survey.
• Relevant data & vital indices.
On the individual's level
• Dietary survey.
• Clinical health appraisal.
• Anthropometric measurements.
• Laboratory investigations.