Public Health Nutrition 191106

7/29/2019 Public Health Nutrition 191106

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PUBLIC HEALTH NUTRITION

Dr. TIRTA PRAWITA SARI, MSc


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Definitions

Clinical nutrition: more in treatment, less prevention andpromotion, personal treatment

Public health nutrition focuses on the promotion of goodhealth (the maintenance of wellbeing or wellness, qualityof life) through nutrition and the primary (and secondary)prevention of nutrition- related illness in the population(nutrition society)


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Malnutrition and death

Inadequate

dietary intake

Disease

Inadequate

access to food

Inadequate

care for mothers

n children

Insufficient health

services n unhealthy

environment

Formal n nonformal

institutions

Economic structure

Potential resources

Political n ideological superstructure

Inadequate education

Immediate

causes

Underlying

causes

Basic

causes

UNICEF s CONCEPTUAL FRAMEWORK OF MALNUTRITION


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The Triple A Cycle

1. Assessment: situationanalysis; identify problems andselect opportunity forimprovement

2. Define the problem

operationally3. Identify who needs to work on

the problem

4. Analyze and study theproblem to identify major

causes5. Develop solutions and action

for quality improvement

6. Implement and evaluatequality improvement effort

analysis

action

assessment


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1.Identintify key nutrition-

related problem

2. Set goal

3. Define objectivesfor goal

4. Create quantitative

targets

5. Develop program

6. Implement

program

7. Evaluate

program

The public health nutrition cycle


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Major nutritional problems in Indonesia

Under-nutrition

Vitamin A deficiencyIodine deficiency disorder

Iron deficiency anemia


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Under-nutrition


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Classification of under-nutrition by based

on NCHS reference (WHO, 1995)

Indicator Z score Classification of

under-nutrition

Weight for age Z score < - 2 SD Underweight

Height for age Z score < - 2 SD Stunting

Weight for height Z score < - 2 SD Wasting


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Mechanism of reduced nutritional status

Decreased nutrient intake

Decreased nutrient absorptionDecreased nutrient utilization

Increased nutrient losses

Increased nutrient requirements


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Nutrition and immunity in under-nutrition

Weight loss, growth

faltering, lowered

immunity, mucosal

damage

Disease; incidence,

severity, duration

Appetite loss,

nutrient loss,

malabsorption,

altered metabolism

Inadequate dietary

intake


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Public health consequences of under-nutrition

Susceptibility to mortality

Susceptibility to acute morbidityDecreased cognitive development

Decreased economic productivity

Susceptibility to chronic diseases in later life


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Malnutrition and death

Inadequate

dietary intake

Disease

Inadequate

access to food

Inadequate

care for mothers

n children

Insufficient health

services n unhealthy

environment

Formal n nonformal

institutions

Economic structure

Potential resources

Political n ideological superstructure

Inadequate education

Immediate

causes

Underlying

causes

Basic

causes


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General guidelines to assist in decisions to implement

nutrition program

Malnutrition rate 20%

Malnutrition rate 15-

19% + aggravating

factors

Malnutrition rate 5-9% +

aggravating factors

Malnutrition rate 10-

15%

Malnutrition rate < 10%

with no aggravating

factors

or

or

SERIOUS

BLANKET supplementary

feeding, supplementary

feeding, THERAPEUTIC

feeding program

ALERT

TARGETED

supplementary feeding,

THERAPEUTIC feeding

program

ACCEPTABLE

No need for population

level interventions

(individual attention for

malnourished

GENERALRATION < 2100

Kcal/pers/day

Always improvegeneral rations

Taken from Care International


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Related Terms

Aggravating factors:

Mortality: crude mortality rate > 1/10.000/day

Inadequate general food rations

Epidemic of measles, shigella or other important communicablediseases

Severe cold and inadequate shelters

Blanket supplementary feeding: provides a quality or energysupplement in addition to the normal ration which is distributed to allmembers or identified vulnerable groups to reduce risk

Targeted supplementary feeding provides energy or quality dietarysupplements and basic health screening to those that are already

moderately malnourished to prevent them from becoming severelymalnourished and improve their nutritional status (curative)

Therapeutic feeding provides a carefully balanced and intensivelymanaged dietary regimen with intensive medical attention, torehabilitate the severely malnourished (curative) and reduce excessmortality


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Prevention

Growth monitoring and nutrition education


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Code Province Prev Code Province Prev Code Province Prev Code Province Prev

11 DI Aceh 15.18 31 DKI-Jkt 12.71 61 Kalbar 23.15 81 Maluku 15.3112 Sumut 17.58 32 Jabar 17.40 62 Kalteng 19.54 82 Papua 15.59

13 Sumbar 19.74 33 Jateng 19.12 63 Kalsel 21.97

14 Riau 16.28 34 DI Jogja 12.05 64 Kaltim 18.04

15 Jambi 18.19 35 Jatim 18.26 71 Sulut 11.86

16 Sumsel 15.30 51 Bali 11.84 72 Sulteng 21.10

17 Bengkulu 15.10 52 NTB 22.22 73 Sulsel 20.10

18 Lampung 15.95 53 NTT 23.09 74 Sultra 17.18

=20%

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PREVALENCE OF MALNUTRITION AMONG UNDER-FIVES

BY PROVINCE, SUSENAS 1999

Source : Ministry of health, 199988


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Code Province Prev Code Province Prev Code Province Prev code Province Prev

11 DI Aceh 10.95 31 DKI-Jkt 5.72 61 Kalbar 11.48 81 Maluku 7.3412 Sumut 11.36 32 Jabar 6.16 62 Kalteng 7.56 82 Papua 9.67

13 Sumbar 7.55 33 Jateng 5.42 63 Kalsel 8.23

14 Riau 8.40 34 DI Jogja 3.58 64 Kaltim 7.57

15 Jambi 9.69 35 Jatim 7.78 71 Sulut 8.24

16 Sumsel 5.93 51 Bali 3.98 72 Sulteng 7.23

17 Bengkulu 9.82 52 NTB 10.64 73 Sulsel 9.01

18 Lampung 8.46 53 NTT 10.13 74 Sultra 5.63

=10%

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PREVALENCE OF SEVERLY MALNOURISHED

AMONG UNDER-FIVES BY PROVINCE, SUSENAS 1999

Source : Ministry of health, 1999 89


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The prevalence of underweight among pre-school children, 2003


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Micronutrients deficiency


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Selected micronutrient deficiencies, consequences,

and strategies (1)

Micronutrient Clinical

manifestatio

ns of

deficiency

Public health

magnitude of

the problem

Effective

interventions

Vitamin A Damage to

cornea and

retina leading

to partial

blindness,increased

severity of

diarrhea and

malaria

100 million

children,

contributory

factor in 3

millionchildhood

deaths

annually

Single dose

supplementati

on

administered

withvaccination


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Selected micronutrient deficiencies, consequences,

and strategies (2)

Micronutrient Clinicalmanifestations

of deficiency

Public healthmagnitude of

the problem

Effectiveinterventions

Iron Anemia, poor

cognitivedevelopment,

increased

susceptibility to

infection

2 billion people

worldwide,mostly women

and children

Fortification,

administration ofsupplements

and

antihookworm

treatment

Iodine Poor cognitivedevelopment 43 millionworldwide,

primarily in

areas where

soils are iodine

poor

Salt iodization


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Vitamin A deficiency


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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 Minimum

prevalence (%)

Clinical (primary)

Night blindness (XN) > 1.0

Bitots spot (X1B) > 0.5

Corneal xerosis/ulceration/keratomalacia

(X2,X3A,X3B)

> 0.01

Xerophtalmia-related corneal scar (XS) > 0.05

Biochemical (supportive)

Serum retinol (vitamin A) < 0.35 mol/l ( 5.0


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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

between6 and 11

months

12-59

months

Mother 200.000 IU*

Infant/child 50.000

IU

50.000

IU

50.000

IU

100.000

IU

200.000

IU every4 6

months

* At delivery and another 200.000 IU during the safe infertile postpartum

period at least 24 h after the first dose


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Different public health approaches to modifying

vitamin A intake used in the prevention and

control of vitamin A deficiency (1)

Food basedDietary diversification

Home gardening

Nutrition education

Development of high carotenoid content varieties of staple foods

Fortification

Sugar

Flour

Margarine, edible oils

NoodlesCondensed milk and other dietary products

Condiments

Other food vehicles


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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 nationalmicronutrient days through health system centers,including maternal and child health program

With expanded program immunization

Postpartum supplementation

Life cycle distribution to adolescents and youngwomen through schools and factory

Complementary public interventions

Ecological, political, and socioeconomic interventions


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Core indicators for assessing the progress of

vitamin A deficiency control program

Indicators Prevalence goal

Functional indicators

Night blindness (children 24 71

months of age)

< 1%

Biochemical indicators

Serum retinol 0.70 mol/l or < 5%

Breast milk retinol 1.05 mol/l or 8

g/g milk fat

< 10%


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Iodine deficiency disorder


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Classification of IDD

Diagnosis of iodine deficiency should be seen as agroup, community, or population diagnosis rather than

an assessment on the individual levelIDD status is interpreted through the summary data ofthe group.

Indonesia: prevalence of goiter decreased from 27.9%(1990) to 11.1% (2003)


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Classification of Iodine status of a population

based on median urinary iodine concentration*

Iodine status Median urinary iodine

concentration (g/l)

Severe Iodine deficiency 300

*As consulted with WHO, UNICEF, and ICCIDD


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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 notvisible when the neck is in the normal position,but moves upwards in the neck as the subjectswallows; nodular alteration can occur even whenthe thyroid is not visibly enlarged

Grade 2: a swelling in the neck that is visiblewhen the neck is in a normal position and isconsistent with an enlarged thyroid when theneck is palpated

By USG


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Reference intake for iodine

(WHO/UNICEF/ICCIDD, 2001)

Category Intake (g/day)

Under-fives, 0-59 months 90

School children, 6-12 years 120

Children > 12 years and adults 150

Pregnant and lactating women 200


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Management of iodine deficiency

Strategies depend on:

The severity of IDD

The accessibility of the target populationThe resources available,

Strategies:

Food-based approaches

Use of natural foods


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Strategy to eliminate IDD

Use of iodized salt

Iodination of drinking water

Fortification of infant formulas

Fortification of other foodsFortification of foods consumed by farm animals

Nutraceutical approaches

Use of iodized oilUse of potassium iodine solution (30 mg everymonth or 8 mg every 2 weeks)


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Evaluation of IDD elimination program

Process indicators:

Coverage of iodized salt at household level inrepresentative sample of a community or population

(household salt with iodine concentration > 15mg/kg, ideally the percentage should exceed 90%)

Outcome indicators:

Urinary iodine secretion

Thyroid size, TSH, and thyroglobulinCretinism

T4 and T3 levels.


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Prevalensi Gondok Anak Sekolah di Indonesia 1998Menurut Propinsi

< 5 %

5 - 19.9 %

20-29.9 %

> 30 %

Keterangan

11 Aceh 5.4%

12 Sumatera Utara 6.7%

13 Sumatera Barat 20.5%

14 Riau 1.1%

15 Jambi 3.7%

16 Sumatera Seleatan 7.3%

17 Bengkulu 7.9%

18 Lampung 11.9%

31 Jakarta 2.0%

32 Jawa Barat 4.5%

33 Jawa Tengah 4.4%

34 Yogyakarta 6.1%

35 Jawa Timur 1 6.3%

51 Bali 12.0%

52 Nusa Tenggara Barat 19.7%

53 Nusa Tenggara Timur 38.1%

54 Timor Timur 21.4%

61 Kalimatan Barat 2.3%

62 Kalimatan Tengah 8.1%

63 Kalimatan Selatan 1.7%

64 Kalimatan Timur 3.1%

71 Sulawesi Utara 3.0%

72 Sulawesi Tengah 16.5%

73 Sulawesi Selatan 10.1%

74 Sulawesi Tenggara 24.9%

81 Maluku 33.3%

82 Papua 13.0%

90


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Iron deficiency anemia


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IDA is considered to be present in a population only

when the prevalence of Hb below the cutoff isgreater 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 55%)


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Hb and Ht cutoffs used to determine anemia*

Age or sex group Hb below (g/dl) Ht below (%)

Children 6 months to 5

years

11 33

Children 5-11 years 11.5 34Children 12-13 years 12 36

Non-pregnant women 12 36

Pregnant women 11 33

Men 13 39

*Source: Indicators for assessing IDA and strategies for its prevention,

WHO/UNICEF/UNU


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Stages of iron depletion

Decrease

in iron stores

Biochemical

Indicators of low

Iron stores

IDA

Stage I

Stage II

Stage III

Feritin

Transferrin saturation

Erythrocyte protoporphyrin

Hemoglobin


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Factors influencing iron absorption

Type of food consume

Interaction between foods

Regulatory mechanisms in the intestinalmucosa

Bioavailability

Amount of iron stores

Rate of production of RBC


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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


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Schematic of integrated strategy for prevention and

control of iron deficiency

Assessment for iron deficiency and IDA

Balance and phase interventions as appropriate

Dietary

ChangeFortification

Of foods

Oral

Supplemention

Infection

control

Research

and

monitoring

Program implementation

Program linkage

FP

Reproductive

health

Breastfeeding

promotion

Expanded program

on immunization

Integrated

management ofchildhood illness


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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 policyWhat interested parties will gain from the policy

The ability of those interested parties to make their

voices heard

Documents

Public Health Nutrition 191106