1. NUTRITION AND HEALTH
BY
Marzouk Al-Khawaga
Ass. Lecturer of Public Health
Damietta Faculty of Medicine
Al-Azhar University

2. • Desirable nutrition - body has enough of the essential nutrients for
normal (homeostatic) function plus reasonable stores for times of
increased need
• Malnutrition
mal = bad,
Really means absence of nutritional health, or nutritional
imbalance: includes significant deficiency or excess over time
• Under-nutrition
-Not consuming enough nutrients to fully meet biological needs
-Mostly associated with poverty, illness, alcoholism, some diseases
• Over-nutrition
-Consistently consuming more than necessary to meet biological
needs
-Overconsumption of fats, calories, cholesterol increase risk of chronic
disease
Nutritional Health

3. Nutritional health
disorders

6. Kwashiorkor
*children of age 1 to 4 years
*weaning years,
*The classical syndrome is that of:
retarded growth and development with mental
apathy,
edema,
muscular wasting, and
depigmentation of hair and skin.

7. Kwashiorkor

9. Marasmus
*in infants of age 6 to 8 months
*it is caused by chronic dietary under-nutrition
*Trigged with the occurrence of repeated diarrhea.
*Some underlying factors such as
low socio-economic,
other diseases such as tuberculosis, gastro-enteritis
parasitic infestations are usually present.,
*It is manifested by gradual wasting

11. Marasmus
1-Very low body weight
2-Severe muscle wasting
3-Loss of subcutaneous fat
4-Absence of edema

12. Marasmic Kwashiorkor
A child with kwashiorkor may develop Marasmic
picture after edema subsides

13. Classification of Protein Energy
Malnutrition
%90% to75Weight for age“Mild”:First degree
of Standard
Weight for age:“Moderate”Second degree
60% to 75% of Standard
Weight for age less than“Severe”:Third degree
60% of Standard.

14. Evaluation of nutritional status is:
A comprehensive evaluation of a person’s
nutrition status.
The interpretation of information obtained from a
variety of methods to identify populations OR
individuals at risk of poor nutritional status.

15. Assessment of
Nutritional Status
Direct Tools:
Dietary Surveys
Clinical Examination
Anthropometry
Biochemical tests
Indirect Tools
Morbidity
Mortality Rates
Ecological
Factors
Magnitude of
Health services
A B C D

16. Nutritional Survey
Objectives:
*To determine the magnitude & geographical
distribution of malnutrition
*To determine underlying ecological factors of
malnutrition
*To plan for control & prevention of malnutrition

17. A-Dietary Surveys
They require:
Updated national statistics on food and
agriculture
Shows the distribution of national food supply
among different groups of the population during
different seasons
•Uses representative samples

18. Dietary Surveys are carried out on
1-Community Level (Food Balanced Sheet)
2-Family Level (Family Surveys):
Family members are recorded according to age, sex
and occupation
Food consumption is measured over
- 24 hours/ 24 hour recall
-over a week or a month
3. Specific Groups
4. Individuals

19. B-Clinical Examination
General Examination:
Skin, eyes, hair, buccal mucosa
Thyroid gland
Disadvantages:
•Non specific (DD: Environmental factors, dryness of
skin of extremities

20. C-Anthropometric Measurements
Weight
Height
Length: < 2 years
Plotted on Growth Chart
Weight for age
Height for age

21. D-Biochemical Examination
1.Serum or plasma
2.Total proteins or amino acids
3.Vit A &carotene Vit C B12
4.Iron, Serum Fe and transferrin
5.Red Blood cell Count
6.Hemoglobin
7.Urine: Creatinine, urea, thiamin, riboflavin

22. D-Biochemical Examination
cont.))
Immunological Tests:
Total Lymphocytic Count
- >200 Normal
- 800-1200 Moderate
- < 800 Severe nutritional deficiency
Skin Test:
- Cell mediated Immunity: delayed
- Humoral Immunity: delayed or no response

23. Indirect tools of Nutritional Assessment
I-Mortality Rates:
Infant mortality Rate
Mortality of under 5 years
Ratio of under 5 mdeats/total deaths
Perinatal mortality rate
Cause specific mortality rate
II- Morbidity Rates

24. III- Ecological Factors
Information about:
No of Heath centers, hospitals
Feeding habits of the community
Feeding of vulnerable groups
Socio economic factors
Income and food prices

25. Anthropometry
Greek ‘anthropos’ = human, ‘metro’ = measurement
Measurement of physical characteristics e.g. height, weight,
body composition (fat!). Compare with standards for age, sex …

26. Anthropometry
Is the measurement of the human body,
Measurements of the variations of the physical dimensions and the
gross composition of the human body at different age levels and
degrees of nutrition
General uses
-To evaluate progress of growth: identify people whose growth is
outside normal values suggesting under or over nutrition
-Screening tool to identify individuals at high risk of malnutrition.
-To measure changes over time: monitor effects of nutrition
intervention for treatment of disease, surgery or malnutrition. Also,
can track weight changes that may indicate disease

27. Anthropometric
data
Uses
Good to track growth in
kids (growth chart)
Typically measure
weight, length, head
circumference (brain
growth)

28. Child Health Program
Well Child Clinic
All infants and children below 5 years should
visit this clinic regularly for the following:
1.A full clinical examination
2.Growth assessment
3.Immunisation according to the schedule of
EPI
4.Treatment of any health problem

29. Child Health Program
Continuous growth monitoring will identify:
Failure to thrive as early as possible
giving chance to adequate
management and intervention

30. Expanded Program of Immunization
Un-immunized children are susceptible
to various infectious diseases

31. What's meant by Growth charts?
* 9 percentile curves (3rd to 97th percentiles)
representing the distribution of weight ,height
(length for less than 36 months) or head
circumference values at each age and sex.
* The percentile curve of weight for age
indicates the % of children at a given age (on the
x axis) whose measured value falls below the
corresponding weight (on the Y axis).

32. What's meant by Growth charts?
1)-The 50th percentile:
Is the median the value above and below which 50% of the
observed values fall.
2)An infant at the 5th of weight for age may be growing
normally or failing to grow or may be recovering from
growth failure.
(DON’T Judge the growth by single value).
3)-Canalization (Way to health):
-growth of the infant and children stay within one or two
growth curves.
-controlled by the genes of the body.

33. Growth Charts

34. What is important?
Is the growth rising ,
declining or
deviating??

35. General aspects for G C Interpretation1
1)Successful readings not single point of drop.
2)Analysis may provides critical information:
a)If the child weight drops down more than two major
percentile lines. (failure to thrive)
b)Decrease in w/a and w/h curves (wasting).
(acute under nutrition)
c)Decrease in h/a curve(stunting).
(several months of caloric deprivation)
(put in mind w/h curve may return to normal again?)
d)sever under nutrition depresses head growth.

36. General aspects for G C Interpretation2
3)Chronically undernourished child is stunted but
not necessarily wasted.
4)It is important to review growth parameters with
the previous values and with parents for occurrence
of diseases that could have caused drop in growth at
different occasions like RTIs,GEs,Mothers death.
5)Put in mind growth pattern of the family as it may
be no problem in a baby below 5th percentile
(Familial short stature).

39. What can we measure?
Indices & ratios to describe body size
Generalised equations to predict body fat
Skinfolds, girths, lengths &
breadths

40. Anthropometric Measurements
1)Length - < 2yrs
2) Height
3)Weight
4)Arm circumference
5)Head circumference
6)Waist circumference / hip circumference
7)Skinfold thickness

41. Anthropometric indices of growth - 1
Head circumference for age
Index of chronic protein energy nutritional status during first 2
yrs of life
Weight for age
Index of acute malnutrition widely used to assess protein energy
malnutrition & over-nutrition in children from 6 months to 7 yrs
.
Limitations include
1.Age often unknown
2.Composition of the weight unknown (lean, fat, oedema,
tumour etc..)

42. Weight for height
Sensitive index of current nutritional status which is relatively
independent of age between one and 10 yrs.
Can be used in conjunction with weight for age.
Height for age
Within populations, heights of children at a given age reflect their
nutritional status
Anthropometric indices of growth - 2

43. Waist circumference
Ref: Han et al, BMJ 1995 311:1401-5
Ideal Increased Risk Greater Risk
male <94 94-101 >102
Female <80 80-87 >88
Girth in centimetres
Cardiovascular Risk
A useful indicator of obesity,
especially of central obesity
Measurement are taken at the
narrowest part of the upper body
(above the “umbilicus”) at the
end of a normal breath

44. Waist circumference / hip circumference
An indicator of body fat distribution
The WHO states that abdominal
obesity is defined as a waist–hip
ratio above 0.90 for males and
above 0.85 for females indicating a
tendency for central fat deposition &
possible  health risk
Hip circumference with clothing
introduces error

45. Skinfold Thickness
•Most of the fat stored in the
body lies immediately under
the skin
•The thickness of a fold of skin
picked at strategic sites
indicates the amount of
subcutaneous fat
•Based on the idea that a
measure of the largest
deposit of body fat may
provide a reasonable estimate
of TOTAL body fat
•Middle of triceps:
•In male: 20cm
•In female: 30cm
fat within subcutaneous
adipose, bone marrow,
visceral and intramuscular
fat

46. Skinfold Thickness at 4 sites

47. Skinfold Thickness
3 measurements made at each site
The median of the 3 readings are calculated and summed
The sum of the 4 skinfolds is then entered into a table (Durnin
& Womersley, 1974), taking the age and sex of the subject into
account.
Examples
In a 24y old male with SFT = 40mm, % body fat = 16.4%
In a 24y old female with SFT = 40mm, % body fat = 23.4%

48. Anthropometric assessment of
body composition
oUnderwater weighing
measures body fat
Archimedes’ principle: an object’s loss of weight in water = the
weight of the volume of water it displaces, because the object in
the water is buoyed up by a counterforce which = the mass of
water it displaces.
oDuel Energy X-ray Absorptiometry (DEXA)
measures bone mass, lean tissue (and fat by difference).
oBioelectrical Impedance Analysis (BIA)
Principle: tissues such as blood or muscle are highly conductive
whereas fat and bone are highly resistive
The volume of these tissues can be estimated from the
measurement of the resistance to an applied electric current
flowing through the body.

49. Underwater weighing

50. Caloric requirements
1)According to physical activity:
*It increases caloric requirements.
*male:40kcal/kg/day
*female: 33kcal/kg/day
2)Body weight:
*It increases caloric requirements
*Man: E=815+36.6w
*Female: E=580+31.1w
(E=caloric needs, w-weight)

51. Caloric requirements(cont.)
3)Age :
-Age reduces the caloric needs
-1st 6 months: 110kcal/kg/day
-Adult: 40kcal/kg/day
4)climate:
*Decreased by 5%for every 10c increase of
external temperature above the reference temp.
*increased by only 3% for every 10c below 10c.

54. +

55. BMI and Obesity
height (m2)/BMI = weight (kg)
This ratio was first suggested as a measure of fatness
by (Quetelet in 1869)
Example: If x weighs 58 kg and he is 165 cm
tall, what is his BMI?

56. Classification of weight in adults
according to BMI (WHO, 1998)
):2(kg/mBMI
-Underweight < 18.5
-Normal range 18.5 - 24.9
-overweight >25
-Obese class I: 30.0 - 34.9
-Obese class II: 35.0-39.9
- Obese class III: > 40
www.food.gov.ukChart from

57. Anthropometric data uses
Identify risk factors for chronic disease i.e. elevated BMI

58. Example(2)
Subject: Male
Age: 48 y
Height: 1.96 m
Weight: 125 kg
Calculate?
BMI: ????
Classification: Obesity ???