1. Importance of Nutrition Principles of Balanced Diet Measuring Nutritional Status and Nutritional Disorders
Prof.Dr.Selma KARABEY

2. Nutrition: “The Good, the Bad, and the Ugly”
Nutrition is the intake of food, considered in relation to the body’s dietary needs.
Good nutrition – an adequate, well balanced diet combined with regular physical activity – is a cornerstone of good health.
Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.
Better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases (such as diabetes and cardiovascular disease), and longevity.

3. The underlying causes of malnutrition at household or community level are household food insecurity; inadequate care for women and children; and an unhealthy environment, including poor sanitation and hygiene and lack of services for health. The causes of malnutrition at national and international level include poverty, inequity, civil unrest, poor governance, inadequate global structures and lack of natural resources.

5. Balanced Diet
An unhealthy diet is one of the major risk factors for a range of chronic diseases, including cardiovascular diseases, cancer, diabetes and other conditions linked to obesity.
Specific recommendations for a healthy diet include: eating more fruit, vegetables, legumes, nuts and grains; cutting down on salt, sugar and fats.
It is also advisable to choose unsaturated fats, instead of saturated fats and towards the elimination of trans-fatty acids.

6. Balanced Diet-2
For diet, recommendations for populations and individuals should include the following:
achieve energy balance and a healthy weight
limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids
increase consumption of fruits and vegetables, and legumes, whole grains and nuts
limit the intake of free sugars
limit salt (sodium) consumption from all sources and ensure that salt is iodized

7. Nutritional Elements Protein 10-20% Carbohydrate 50-70% Fat 20-30%
Vitamins
Minerals
Water

8. Special groups for nutrition
Infants and young children 
School age children
Fertile women
Pregnants
Breastfeeding
Elderly
Handicapped people

13. Carbohydrates Carbohydrates are our body's main energy source.
Our brain is fueled by carbohydrates.
Carbohydrates occur in a variety of forms: simple sugars, more complex starches and fiber.
They are found naturally in legumes, grains, vegetables, fruits and milk. They're also added to baked goods and many other foods.
It is important to emphasize natural, nutrient-dense carbohydrates from fruits and vegetables, beans and legumes, and whole grains. We also must limit less healthy sugar-sweetened beverages, desserts and refined grain products.We have to get 45 to 65 percent of our daily calories from carbohydrates. Carbohydrates have 4 calories a gram. Based on a 2,000-calorie-a-day diet, this amounts to 900 to 1,300 calories a day, or about 225 to 325 grams.

14. Carbohydrates
We have to get 45 to 65 percent of our daily calories from carbohydrates.
Carbohydrates have 4 calories a gram.
Based on a 2,000-calorie-a-day diet, this amounts to 900 to 1,300 calories a day, or about 225 to 325 grams.
It is important to emphasize natural, nutrient-dense carbohydrates from fruits and vegetables, beans and legumes, and whole grains. We also must limit less healthy sugar-sweetened beverages, desserts and refined grain products.We have to get 45 to 65 percent of our daily calories from carbohydrates. Carbohydrates have 4 calories a gram. Based on a 2,000-calorie-a-day diet, this amounts to 900 to 1,300 calories a day, or about 225 to 325 grams.

15. Carbohydrates
Fiber;
Fiber is the part of plant-based foods that our body doesn't digest and absorb. There are two basic types of fiber: soluble and insoluble.
Soluble fiber may help improve our cholesterol and blood sugar levels. Oats, dried beans and some fruits, such as apples and oranges, are good sources of soluble fiber.
Insoluble fiber adds bulk to our stool and can help prevent constipation. Vegetables, wheat bran and other whole grains are good sources of insoluble fiber.
It is important to emphasize whole-grain products, fruits, vegetables, beans and peas, and unsalted nuts and seeds. If you're a woman, you have to get about 22 to 28 grams of fiber a day. If you're a man, you have to get about 28 to 34 grams of fiber a day.

16. Carbohydrates
Sugar
All sugar, whether natural or processed, is a type of carbohydrate that our body uses for energy.
Sugar occurs naturally in some foods, including fruits, vegetables, milk and some grains.
Sugar is also added to foods and beverages. These added sugars do little more than add calories to our diet. Many processed foods that have added sugar also contain solid fats.
We have to cut back on calories from added sugar and solid fats. For most people, that means cutting their intake to no more than 5 to 15 percent of total calories. (Consider that 13 percent of a 2,000-calorie diet is about 260 calories a day.) We must limit table sugar, desserts, pizza, sausage and similar fatty meats, sweetened beverages, candy, stick margarine and butter.
The American Heart Association has specific guidelines for added sugar — no more than 100 calories a day from added sugar for most women and no more than 150 calories a day for most men. That's about 6 teaspoons for women and 9 for men.

17. Protein
Protein is an important nutrient, essential for growth and development.
All the cells of our body include protein.
Protein is also an important source of calories and energy.
Both plant-based and animal-based foods provide protein.
It is important to emphasize plant sources of protein, such as beans, lentils, soy products and unsalted nuts. These high-protein foods have the added bonus of being higher in health-enhancing nutrients than are animal sources of protein. We have to eat seafood twice a week. Meat, poultry and dairy products should be lean or low fat.We have to get 10 to 35 percent of our total daily calories from protein. Protein has 4 calories a gram. Based on a 2,000-calorie-a-day diet, this amounts to about 200 to 700 calories a day, or about 50 to 175 grams a day.

18. Fats Fats aren't necessarily bad for us.
Dietary fat is a nutrient that helps our body absorb essential vitamins, maintains the structure and function of cell membranes, and helps keep our immune system working.
Some types of fat, though, may increase our risk of heart disease and other health problems.
Fat also has a lot of calories, increasing the risk of weight gain.
It’s important to emphasize unsaturated fats from healthier sources, such as lean poultry, fish and healthy oils, such as olive, canola and nut oils. We have to limit less healthy full-fat dairy products, desserts, pizza, burgers, sausage and other fatty meats. To keep fat at bay, we should limit all sources of fat to 20 to 35 percent of our daily calories. Fat has 9 calories a gram. Based on a 2,000-calorie-a-day diet, this amounts to about 400 to 700 calories a day, or about 44 to 78 grams of total fat.

19. Fats
Saturated fat
Saturated fat is most often found in animal products, such as cheese, red meat, poultry, butter and whole-milk products.
Other foods high in saturated fat include those made with coconut, palm and other tropical oils.
Saturated fat may increase our risk of heart disease and type 2 diabetes.
We have to limit saturated fat to no more than 10 percent of our total calories
We should replace saturated fats with healthier monounsaturated fats and polyunsaturated fats, found in olive oil, canola oil, vegetable oils, lean poultry, and unsalted nuts and seeds.Saturated fat counts toward our total daily allowance of fat.We have to limit saturated fat to no more than 10 percent of our total calories. Lowering calories from saturated fat to 7 percent can further reduce our risk of heart disease. Saturated fat has 9 calories a gram. Based on a 2,000-calorie-a-day diet, 7 to 10 percent amounts to about 140 to 200 calories a day, or about 16 to 22 grams of saturated fat.

20. Fats
Trans fat
Trans fat occurs naturally in some foods, especially foods from animals. But most trans fat is created during food processing through partial hydrogenation of unsaturated fats.
Trans fat is found in some types of margarine, shortening, snack foods and commercial baked goods.
Trans fat can increase our risk of heart disease.
To avoid trans fat as much as possible by limiting foods that contain synthetic sources of trans fat, such as partially hydrogenated oils, and by limiting other solid fats. We have to cut back on commercially prepared desserts and snacks, such as crackers, cookies, cakes and doughnuts. Remember trans fat counts toward our total daily allowance of fat.

21. Cholesterol
Cholesterol is vital because it helps build our body's cells and produces certain hormones.
But our body makes enough cholesterol to meet its needs — we don't need any dietary cholesterol.
Excessive cholesterol in our diet can increase our risk of heart disease and stroke.
Dietary cholesterol comes from animal products, such as meat, poultry, seafood, eggs, butter and other dairy products.
We have to keep dietary cholesterol to less than 300 milligrams a day. As cutting cholesterol to less than 200 milligrams a day can benefit anyone at high risk of heart disease. We can reduce dietary cholesterol by cutting back on animal sources of food, such as beef, poultry and egg yolks. If an item is high in saturated fat, it's probably also high in cholesterol

22. Sodium
Some sodium is vital because it helps maintain the right balance of fluids in our body, helps transmit nerve impulses, and influences the contraction and relaxation of muscles.
Too much sodium, though, can be harmful, increasing our blood pressure and the risk of heart disease and stroke.
We must reduce sodium in our diet by limiting processed and prepared foods, which are often high in sodium. Also we should avoid salty condiments.We mustn’t add salt at the table, and should eliminate it from recipes when possible. We should limit sodium to less than 2,300 milligrams a day — or 1,500 milligrams if we're at the age of 51 or older, if we are black, or if we have high blood pressure, diabetes or chronic kidney disease

23. Direct Methods of Nutritional Assessment
Nutrition is assessed by two types of methods; direct and indirect.
The direct methods deal with the individual and measure objective criteria, while indirect methods use community health indices that reflects nutritional influences.

24. Direct Methods of Nutritional Assessment-2
These are summarized as ABCD
Anthropometric methods
Biochemical, laboratory methods
Clinical methods
Dietary evaluation methods

25. Indirect Methods of Nutritional Assessment
These include three categories:
Ecological variables including crop productio
Economic factors e.g. per capita income, population density and social habits
Vital health statistics particularly infant and under 5 mortality and fertility index

26. Measuring Nutritional Status

27. Anthropometric Methods
Anthropometry is the measurement of body height, weight and proportions.
It is an essential component of clinical examination of infants, children and pregnant women.
It is used to evaluate both under and over nutrition.
The measured values reflects the current nutritional status and don’t differentiate between acute and chronic changes .
Anthropometry for children:Accurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child.For growth monitoring the data are plotted on growth charts over a period of time that is enough to calculate growth velocity, which can then be compared to international standards
ADVANTAGES OF ANTHROPOMETRY:Objective with high specificity & sensitivity
Measures many variables of nutritional significance (Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI).
Readings are numerical & gradable on standard growth charts
Readings are reproducible.
Non-expensive & need minimal trainin
Limitations of Anthropometry:
Inter-observers errors in measurement
Limited nutritional diagnosis
Problems with reference standards, i.e. local versus international standards.
Arbitrary statistical cut-off levels for what considered as abnormal values.

29. Other anthropometric Measurements
Mid-arm circumference
Skin fold thickness
Head circumference
Head/chest ratio
Hip/waist ratio

30. Measurements for adults
Height:
The subject stands erect and bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault and height is recorded to the nearest 0.5 cm.
Weight Measurement
Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable.
Weigh in light clothes, no shoes
Read to the nearest 100 gm (0.1kg)

31. Nutritional Indices in Adults
The international standard for assessing body size in adults is the body mass index (BMI).
BMI is computed using the following formula: BMI = Weight (kg)/ Height (m²)
Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity and mortality

32. BMI (WHO - Classification)
BMI < = Under Weight
BMI = Healthy weight range
BMI = Overweight (grade 1 obesity)
BMI > = Obese (grade 2 obesity)
BMI > = Very obese (morbid or grade 3 obesity)

33. Waist/Hip Ratio
Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm.
The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together.
The measurement should be taken at the end of a normal expiration.

34. Waist circumference
Waist circumference predicts mortality better than any other anthropometric measurement.
It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identified
MALES FEMALE
LEVEL > 94cm > 80cm
LEVEL > 102cm > 88cm
Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no further weight gain.
Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes & CVS complications

35. Hip Circumference
is measured at the point of greatest circumference around hips and buttocks to the nearest 0.5 cm.
The subject should be standing and the measurer should squat beside him.
Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.

36. Interpretation of WHR
High risk WHR= >0.80 for females and =>0.95 for males
Indicates central (upper body) obesity and is considered high risk for diabetes and CVS disorders.
A WHR below these cut-off levels is considered low risk.

37. DIETARY ASSESSMENT
Nutritional intake of humans is assessed by five different methods. These are:
24 hours dietary recall
Food frequency questionnaire
Dietary history since early life
Food dairy technique
Observed food consumption

38. 24 Hours Dietary Recall
A trained interviewer asks the subject to recall all food and drink taken in the previous 24 hours.
It is quick, easy and depends on short-term memory, but may not be truly representative of the person’s usual intake.

39. Food Frequency Questionnaire
In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency and quantity) per day, per week and per month.
Inexpensive, more representative and easy to use.
Limitations:
Long Questionnaire,
Errors with estimating serving size,
Needs updating with new commercial food products to keep pace with changing dietary habits.

40. DIETARY HISTORY
It is an accurate method for assessing the nutritional status.
The information should be collected by a trained interviewer.
Details about usual intake, types, amount, frequency and timing needs to be obtained.
Cross-checking to verify data is important.

41. FOOD DAIRY
Food intake (types and amounts) should be recorded by the subject at the time of consumption.
The length of the collection period range between
1-7 days.
Reliable but difficult to maintain.

42. Observed Food Consumption
The most unused method in clinical practice, but it is recommended for research purposes.
The meal eaten by the individual is weighed and contents are exactly calculated.
The method is characterized by having a high degree of accuracy but it’s expensive ,also needs time and efforts.

43. Interpretation of Dietary Data
1. Qualitative Method
Using the food pyramid and the basic food groups method.
Different nutrients are classified into 5 groups (fat and oils, bread and cereals, milk products, meat-fish-poultry, vegetables and fruits)
Determine the number of serving from each group and compare it with minimum requirement.

44. Interpretation of Dietary Data/2
2. Quantitative Method
The amount of energy and specific nutrients in each food consumed can be calculated using food composition tables and then compare it with the recommended daily intake.
Evaluation by this method is expensive and time consuming, unless computing facilities are available.

45. Initial Laboratory Assessment
Hemoglobin estimation is the most important test, and useful index of the overall state of nutrition. Besides anemia, it also tells about protein and trace element nutrition.
Stool examination for the presence of ova and/or intestinal parasites
Urine dipstick and microscopy for albumin, sugar and blood
Specific Lab Tests:
1) Measurement of individual nutrient in body fluids (e.g. serum retinol, serum iron, urinary iodine, vitamin D)
2)Detection of abnormal amount of metabolites in the urine (e.g. urinary creatinine/hydroxyproline ratio)
3)Analysis of hair, nails and skin for micro-nutrients.
Advantages of Biochemical Method:
1)It is precise, accurate and reproducible.
2)Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24-hour urinary excretion.
Limitations of Biochemical Method:
1)Time consuming
2)Expensive
3)They cannot be applied on large scale
4)Needs trained personnel & facilities

46. References
Oxford Textbook of Public Health, Food and Nutrition, Roger Detels, Robert Beaglehole, Mary Ann Lansang, Martin Gulliford, Oxford Univercity Press, 2009
IMPROVING CHILD NUTRITION, The achievable imperativefor global progress, United Nations Children’s Fund (UNICEF)April 2013
Global nutrition policy review:What does it take to scale up nutrition action? World Health Organization 2013
Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition, World Health Organization 2013
WHO child growth standards and the identification of severe acute malnutrition in infants and children, A Joint Statement by the World Health Organization and the United Nations Children’s Fund, World Health Organization and UNICEF 2009
Infant and young child feeding : model chapter for textbooks for medical students and allied health professionals, World Health Organization 2009
Halk Sağlığı Temel Bilgiler, Toplum Beslenmesi, Prof.Dr.Çağatay Güler, Prof.Dr.Levent Akın, Hacettepe Üniversitesi Yayınları 2012

47. Web Sources
Healthy diet: Do you follow dietary guidelines?,Dr.John Noseworthy,
healthy/MY02264/NSECTIONGROUP=2 (last access date: )
Assessment of Nutritional Status, Abdelaziz Elamin, Collage of Medicine Sultan Qaboos University, Oman (last access date: )