Public Health Nutrition

What Is Public Health Nutrition? Strives to improve or maintain optimum nutritional health of the whole population and high risk or vulnerable subgroups within the population. Emphasizes health promotion and disease prevention but may include therapeutic and rehabilitative services when these needs are not adequately addressed by other parts of the health care system.

Uses multiple, coordinated strategies to reach and influence the community, and organizations and individuals that make up the community. Requires organized and integrated community nutrition efforts with leadership provided by the state and local health agency

Community nutrition efforts involve a wide range of programs that provide increased access to food resources, nutrition information and education, and health-related care. They also include efforts to change behavior and environments and to initiate policy.

What types of organizations do this kind of work? Many types of organizations are involved in public health/community nutrition work. Leadership of community nutrition efforts is usually provided by a public health nutritionist employed in an "official" public health agency–a state, city, or county health department.

Public-private partnerships or coalitions are frequently formed to address priority nutrition problems in the community. Ideally, organizations providing nutrition-related programs communicate and coordinate to effectively address nutrition problems and avoid service gaps

Why is it important to know about public health nutrition? * Adequate nutrition for all is the goal Adequate food and balanced nutrient intake are basic necessities for life, health and well being. Adequate nutrition is especially important in periods of rapid growth and development. Poor nutrition during pregnancy, infancy, childhood and adolescence can mean stunted physical, mental and social development with lifelong consequences.

* Dietary factors are associated with five of the ten leading causes of death Coronary heart disease some types of cancer (colon cancer) stroke non-insulin dependent diabetes (type 2 diabetes), and atherosclerosis. Currently attention is focused on total caloric intake; amount and type of fat; vitamins such as folic acid and the antioxidants of vitamins A, C and E; minerals such as calcium; Overweight and obesity an important contributing factor for disease and disability.

* Maternal and child nutrition sets the stage for life The health of mothers and infants has historically been a focus of public health and public health nutrition. Now attention is also directed to preconception concerns such as folic acid intake and its association with neural tube defects

Breastfeeding for the first year of life is recommended because of its many benefits to infants and their mothers Childhood is a time when food preferences and habits are shaped. Low calcium intake of girls and young women sets the stage for osteoporosis in later years

*Vulnerable subgroups are at high risk for nutritional problems Low incomes, Some racial and ethnic minority groups, people with disabilities (defined as functional impairments) experience a disproportionate amount of preventable illness and premature death.

* Behavior change is challenging Nutrition behavior (Food selection, preparation and consumption) is the product of: Culture, Education, Economics, Food availability Social strata Health status Nutritional status depends on all those factors plus biological and genetic factors.

Guiding all members of the population toward more healthful food choices and optimum nutritional health is a great challenge. And doing so early enough to prevent the development of disease is a goal of public health nutrition. Meeting this challenge requires the use of multiple, reinforcing behavior change strategies, including food and nutrition information and education.

Other strategies include: Structuring the environment to enable positive food choices (e.g., juice machines replace pop machines) Modifying food ingredients and preparation techniques to reduce fat content Improving the availability of foods such as fruits and vegetables, and Enacting legislation and regulation (such as required nutrition labels on food packages).

Malnutrition is a multifactorial condition caused by inadequate intake or inadequate digestion of nutrients. It may result from eating an inadequate or unbalanced diet, digestive problems or other medical conditions. OR "A state of nutrition in which a deficiency, excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue, function and clinical outcome." (BAPEN, British association of parenteral and enteral nutrition)

Causes of Malnutrition Famine (severe hunger). Poverty. Digestive disease. Mal-absorption. Depression. Anorexia nervosa. Bulimia nervosa.

Untreated diabetes mellitus. Fasting. Coma Alcoholism and other certain drug addictions Over-consumption of fat and sugar Overpopulation Industrial food processing

Consequences of malnutrition: Impaired immune responses Reduced muscle strength and fatigue Increased difficulties in breathing Impaired thermoregulation Impaired wound healing

Apathy, depression and self-neglect Poor libido Longer hospital stay Higher health costs Higher morbidity Higher mortality

Micronutrient deficiencies Iron deficiency Iodine deficiency Vitamin A deficiency Folic acid deficiency

Nutritional assessment Comprehensive process of identifying and evaluation nutritional problems (risk factors) and needs (nutrients, education, special diet) and determining nutritional status, uses appropriate, measurable methods to gather and evaluate data, by 4 techniques/categories:

History / diet history Clinical /physical examination Anthropometrics (weight, height, mid arm circumference, BMI etc). Biochemical tests (CBC, vitamins level, TFTs)

Height for age (stunting) reflects chronic malnutrition among children. Weight for height (wasting) reflects acute malnutrition. Weight for age (underweight) reflects both acute and chronic malnutrition.

Protein energy malnutrition Causes and consequences: Protein-energy malnutrition (PEM) is a problem in many developing countries, most commonly affecting children between the ages of 6 months and 5 years. The condition may result from lack of food or from infections that cause loss of appetite while increasing the body’s nutrient requirements and losses

Lowered resistance to infection, Children between 12 and 36 months old are especially at risk since they are the most vulnerable to infections such as gastroenteritis and measles. Chronic PEM has many short-term and long-term physical and mental effects including : Growth retardation, Lowered resistance to infection, and increased mortality rates in young children Even after treatment begins it is not uncommon for deaths to result from electrolyte imbalance, hypothermia, or complicating infections.

Nutritional Marasmus It results from prolonged starvation. It may also result from chronic or recurring infections with marginal food intake. The main sign is a severe wasting and the child appears very thin and has no fat . The affected child (or adult) is very thin (“skin and bones”), most of the fat and muscle mass having been expended to provide energy. There is severe wasting of the shoulders, arms, buttocks and thighs, with no visible rib outlines.

Associated signs of the condition A thin “old man “face. “ Baggy pants “ (the loose skin of the buttocks hanging down). Affected children may appear to be alert in spite of their condition. There is no oedema (swelling that pits on pressure) of the lower extremities. Ribs are very prominent.

Kwashiorkor It usually affects children aged 1–4 years, although it also occurs in order children and adults. The main sign is oedema, usually starting in the legs and feet and spreading, in more advanced cases, to the hands and face. Because of Oedema, children with kwashiorkor may look “fat” so that their parents regard them as well fed.

Associated signs Hair changes : loss of pigmentation; curly hair becomes straight easy pluck-able; Skin lesions and hypo-pigmentation, outer layers of skin may peel off and ulceration may occur; the lesions may reassemble burns. Children with Kwashiorkor are usually apathetic, miserable, and irritable. They show no signs of hunger, and it is difficult to persuade them to eat.

The associated signs of Kwashiorkor do not always occur The associated signs of Kwashiorkor do not always occur. In some cases, Oedema may be the only visible sign

Chronic malnutrition Children who suffer from chronic malnutrition fail to grow to their full genetic potential, both mentally and physically. The main symptom of this measured is stunting - shortness in height compared to others of the same age group - and takes a relatively long time to develop

What causes chronic malnutrition? What happens to children who are stunted? How much mortality is caused by malnutrition? How many stunted children are there in the world and where is the problem the greatest?

Every year, over 10 million children under the age of 5 die globally; malnutrition is directly or indirectly associated with more than half of these deaths. According to UNICEF, there were an estimated 170 million stunted children living in developing countries in 2005. South Asia is the region with the highest percentage of its under-5 population stunted. Burundi's population has the most severe level of chronic malnutrition, but India has the largest absolute number of stunted children.

Obesity

WE EAT TO LIVE NOT LIVE TO EAT

Obesity can be defined as a condition of abnormal or excessive fat accumulation adipose tissue; to the extent that health may be impaired (WHO 1998)

Body mass index (BMI) is a simple index of weight-for-height that is commonly used in classifying overweight and obesity in adult populations and individuals. It is defined as the weight in kilograms divided by the square of the height in meters (kg/m2).

WHAT CAUSES OBESITY AND OVERWEIGHT? The fundamental cause of obesity and overweight is an energy imbalance between calories consumed on one hand, and calories expended on the other hand. Global increases in overweight and obesity are attributable to a number of factors including:

a global shift in diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins, minerals and other micronutrients; and a trend towards decreased physical activity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization

Obesity, an epidemic World Health Organization, Geneva 2000 Obesity is a health problem in its own right and is considered a major risk factor in the development of diabetes and cardiovascular disease. There are around 16 million diabetics in the Eastern Mediterranean Region. This figure was expected to rise almost 43 million by 2025.

Physical exercise had become a leisure activity; people had air-conditioned cars and bought their food from supermarkets. Along the same lines, dietary habits had undergone a major change as well. Fat consumption rose, fast food outlets were found every where and most inhabitants of the Gulf Cooperation Council countries reportedly had processed foods at every meal.

Salient features of the obesity epidemic are as follows Obesity is a complex, multifaceted disorder; Obesity is prevalent in both developing and industrialized countries In many countries, especially developing countries, obesity co-exists with under-nutrition; Obesity affects children and adolescents, as well as the adult population

More women have become obese than men, while there is a higher proportion of overweight men than overweight women; Obesity is a major risk factor for serious non-communicable diseases, such as cardiovascular disease, hypertension, stroke, diabetes mellitus and various forms of cancer; It is projected that by 2025 approximately 60% of deaths worldwide will be caused by circulatory diseases and cancers. This evidence suggests that the prevention and control of the problem of obesity needs to be taken very seriously in both industrialized and developing countries.

The economic costs of overweight and obesity Determining the economic cost of obesity is an important activity which can highlight the true impact of the obesity problem for policy-makers in a language they understand-money. The costs of obesity are usually divided into three components:

Direct costs: health care resources for the management of obesity and related illness Indirect costs: loss of economic activity due to illness and premature death associated with obesity. Intangible costs: social and personal loss associated with obesity and its related illnesses.

MDG (millennium development goals) Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality

Improve maternal health Combat HIV/AIDS and other diseases Ensure environmental sustainability Develop a global partnership for development

Balanced nutrition contributes to: Child survival Better education Poverty alleviation Reproductive health Sustained economic growth Global equity, stability and prosperity

According to the Palestinian central bureau of statistics (5/11/2005) 3.5% of children aged 6-59 months in the Palestinian Territory are underweight or too thin for their age (4.0% in the West Bank and 2.6% in Gaza Strip). 9.0% of children are stunted or too short for their age (8.0% in the West Bank and 10.5% in Gaza Strip), and 2.5% are wasted or too thin for their height (2.9% in the West Bank and 2.0% in Gaza Strip

Birth weight: Approximately 9 Birth weight: Approximately 9.6% of infants in the Palestinian Territory (10.3% in the West Bank and 8.3% in Gaza Strip) are estimated to weigh less than 2,500 grams at birth. Breast feeding: show that 95.8% of children aged 6-59 months were breast-fed, of them 96.0% in the West Bank and 95.7% in Gaza Strip

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