DPC

Nutrition and Nutritional Disorders

Dr. Remigio Z. Butacan July 7, 2015

OUTLINE Function depends on your age group

I. Nutrition and Malnutrition
A. Nutrition Nutrition is more for GROWTH during your formative years,
B. Malnutrition MAINTENANCE during your adult years, and REPAIR during
II. The Food Pyramid your geriatric years.
III. Dietary Reference Intake
IV. Nutritional Framework
V. Nutritional Deficiencies
A. Protein Energy Malnutrition (PEM)
1. Marasmus
2. Kwashiorkor
B. Recognition of PEM
C. Classification of Malnutrition
1. Waterlow Classification
a. Calculation for wasting
b. Calculation for stunting Figure 1. Growth, Maintenance, and Repair for all age groups
2. Gomez Classification
3. Wellcome Classification - Food is not a fuel; its a source of raw materials for your body.
VI. Health teams & Government Nutrition Programs B. Malnutrition
A. Health teams One of the worlds major problems
B. Government institutions that conduct nutritional Estimated 1.6-4.4% of the worlds population is severely
programs undernourished;
C. Government nutrition programs Highest numbers in developing countries such as
D. 8th National Nutritional Survey countries in Asia, Africa and Latin America
OBJECTIVES Population at risk: young children, pregnant or lactating
At the end of the lecture, the student should be able to: women from low-income families
1. To have an overview of the concept of nutrition II. THE FOOD PYRAMID
2. To describe the Environment-Agent-Host interactions in - The representation of the distribution of the types of food that you
nutrition need to intake to have very balanced diet.
3. To be aware of the current nutritional status of the country

BOLD emphasis; Italicized quoted/paraphrased from Dr. Butacan

I. NUTRITION AND MALNUTRITION
A. Nutrition
DICTIONARY DEFINITION (Merriam-Webster):
o The act or process of nourishing or being nourished
o The sum of the processes by which an animal or plant
takes in and utilizes food substances
SCIENTIFIC DEFINITION (Food and Nutrition Council of
the American Medical Association):
o The science of food, the nutrients and other
substances therein
o Their action, interaction and balance in relation to Figure 2. The Food Pyramid (Food and Research Institute of the
health and disease DOST)
o The different processes by which the organism
ingests, digests, absorbs, transports, utilizes, - A new addition to the base of the food pyramid is the need for
and excretes food substances. exercise, and hygiene (both personal and environmental)
FUNCTION:
o Growth - The foundation of a balanced diet is water/beverages we live
o Maintenance in the tropics so we need to stay hydrated
o Repair
- Having a fat free diet is bad fat soluble vitamins (A, D, E, K)
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 - Each nutrient has its own graph
III. DIETARY REFERENCE INTAKE
- Amount of raw materials you should have
Established through:
Observations of intakes in healthy populations
Epidemiological observations
Balance studies
Depletion/repletion studies
Animal experiments
Biological measurements

Table 1: Dietary Reference Intake Measurements

Measurement Meaning
Estimated Average Nutrient intake value estimated to
Requirement meet the requirement of half the
(EAR) healthy individuals in a group
Average requirement of healthy
individuals in which
functional/clinical assessments were
conducted and adequacy
INCREASING INTAKE
determined; based on limited human Figure 3. Level of the population for a particular intake of a nutrient
studies
Recommended The level of intake of a nutrient that - Between the 2SDs, that area is 95% of the population
Dietary Allowance takes care of the needs of 97.5% of - Divide it by two (2SD is equal to 47.5%)
(RDA) the population
- EAR 50%
If SD is not given, estimation is 1.2
- EAR + 2SD = 97.5%
x EAR
Adequate Intake Estimate of the RDA based on
(AI) approximations of nutrient intake of
a group of healthy people
Tolerable Upper Highest level of daily nutrient intake
Intake Level likely to pose no risks of adverse
(UL) health effects to the general
population
As intake increases above the UL,
the potential risk of adverse effects
increases
Recommended Level of intake of energy and
Energy and nutrients which are considered
Nutrient Intake adequate for the maintenance of
(RENI) health and well-being of nearly all
healthy persons in a certain
population
Basis: energy and essential
nutrients
Nutrient must be sufficient to meet Figure 4. Curve that represents risk of inadequacy and risk of
the energy requirement for specific
excess
age groups
How much calories are actually
contributing to a specific need of a - EAR 50% risk of inadequacy
specific age group of a specific - UL level of intake where you begin to have a risk of excess
gender? - Area between RDA and UL Adequate intake, low chance of
inadequacy for a particular intake
- RENI same as RDA, but stresses more on the level of nutrients
and not diet

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 IV. NUTRITIONAL FRAMEWORK B. Recognition of PEM
ENVIRONMENT:
o Geography particular places have different - Weight-for-Height is the most useful reference to
accessibilities and various produce distinguish a child who is currently/acutely
(Benguet veggies ; Island seafood) malnourished
o Natural Calamities typhoons and earthquakes change
environment and may diminish their availability (Low weight for both age and height) from a child who
o Advertising is symmetrically stunted (low weight for age but
o Government policies normal weight for height) due to a previous chronic
o Financial capabilities malnutrition
AGENT: Food
o Nutritional content C. Classification of Malnutrition
o Palatability
HOST: Body 1. Waterlow Classification
o Genetics
o Allergies a. Calculation for wasting: refers to acute
o Diseases malnutrition
(Those with arthritis should avoid purine-rich food, which
is broken down into uric acid)

[ ] %
Disrupting a balance among these three factors leads to problems
with nutrition
V. NUTRITIONAL DEFICIENCIES Normal: 90% of reference standard
A. Protein Energy Malnutrition (PEM) Mildly Wasted: 80-90% of reference standard
One of the most serious and widespread forms of Moderately Wasted: 70-80% of reference standard
malnutrition in developing countries Severely Wasted: <70% of reference standard
Encompasses all degrees of energy and protein
deficiency b. Calculation for Stunting: refers to chronic
Severe PEM is fatal malnutrition
Impairs mental development

1. Marasmus

[ ] %
o From the Greek word for withering
o Severely wasted, underweight young child
o Caused by a diet which is very low in protein and Normal: 95% of reference standard
calories Mildly Wasted: 90-95% of reference standard
o balanced starvation Moderately Wasted: 80-90% of reference standard
2. Kwashiorkor Severely Wasted: <80% of reference standard
o Primary cause is a nutritional imbalance in early
childhood due to a diet that is very low in protein,
2. Gomez Classification
but contains calories in the form of
carbohydrates Approximates grading as to prognosis
o Common in places where starchy food are the main
staple Weight for Age* Status
o Inadequately supplemented by protein-rich food of 91-100 normal
vegetable or animal origin 76-90 first degree malnutrition
61-75 second degree malnutrition
Young children are most vulnerable to PEM because: <60 third degree malnutrition
Due to rapid growth, their nutrient requirements are high (e.g., kwashiorkor/marasmus)
Weaning food in inadequate amounts or given late
Over-diluted milk formula *based on the 50th percentile of weight for age
Unhygienic preparation leading to gastroenteritis
Food low in energy and nutrient density (gruels)
Children are active and mobile, and thus, are exposed to new
sources of infection
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 3. Wellcome Classification Belly Gud for Health DOH program
Based on the degree of weight loss and the o Promotes increased activities for their employees
presence/absence of edema o Target Females: 31.5 in ; Males: 33.5 in

Table 2. Wellcome Classification D. 8TH National Nutritional Survey

Conducted by The Food and Nutrition Research Institute
Weight as (+) Edema (-) Edema
Percentage of the Department of Science and Technology (FNRI-
60-80% Kawashiorkor Undernutrition DOST)
<60% Marasmic-Kwashiorkor Marasmus Mandated by Executive Order 128 Section 22
o Reorganizing the National Science and Technology
VI. HEALTH TEAMS & GOVERNMENT NUTRITION Authority
PROGRAMS Conducted from June 2013 April 2014 (roughly every 5
A. Health Teams years)
Does nutritional surveillance to obtain the following data: o Covers: 17 regions, 79 provinces, 45,047
o Surveys households, 172,323 individuals
o Demographic data (morbidity reports, age-specific
mortality rates, birth weights, weights for age, heights
at school entry age)
Implements nutrition related programs such as:
o Nutrition intervention
o Integration of nutrition into the routine healthcare
delivery system (especially the maternal and child
health service)
o Nutritional advice during breastfeeding, weaning and
pregnancy
o Early recognition and treatment of malnourished
children
o Nutrition training
o Informal in-service training Figure 5. Prevalence of underweight Filipino children aged 0-5
years old (2013)
B. Government institutions that conduct nutritional
programs: - Far from our MDG target 13.3% (by 2015)
Department of Science and Technology (DOST)
Food and Nutrition Research Institute (FNRI) DOST
in charge of surveys regarding nutrition
National Nutrition Council (NNC)
Department of Health (DOH)

C. Government Nutrition Programs:

Philippine Plan of Action for Nutrition (PPAN)
Accelerated Hunger-Mitigation Program (AHMP)
o Food for School program 1 kg of iron fortified rice
is given daily to families that suffer severe hunger
through preschool and elementary school children Figure 6. Prevalence of stunting in Filipino children aged 0-5 years
o Tindahan Natin program cooperation in local old (2013)
communities to have access to proper nutrition at
affordable cost
Promote Good Nutrition (PGN) incentive to mothers who
give proper nutrition to their young ones
Barangay Nutrition Scholar (BNS) barangay health
worker volunteers as an agent of nutrition in a barangay;
are qualified for a post in the government (allowed to take
the civil service exam)

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 Figure 10. Prevalence of Chronic Energy Deficiency (CED) and
Figure 7. Prevalence of wasting/thinness in Filipino children aged obesity in Filipinos (2013)
0-5 years old (2013)

- Underweight is weight for age

- Wasting is weight for height
If youre stunted, you are underweight but may not necessarily be
wasted (may have right weight for your height)

Figure 11. Prevalence of nutritionally-at-risk Filipino mothers and

who are susceptible of being nutritionally-at-risk mothers (2013)

Who are nutritionally-at-risk mothers?

Young mothers
Pregnant mothers from rural areas
Mothers in their first trimester
Mothers in poor communities
Figure 8. Comparison of prevalence of underweight, stunting and
wasting/thinness in Filipino children aged 5-10 years old from 2011 REFERENCES
to 2013 8th National Nutrition Survey (2013-2014), Food and
Nutrition Research Institute
- 5% Filipino children ages 0- 5 are overweight Plans and Programs of the National Nutrition Council
- 9.1% (1 in 10) Filipino children ages 5-10 are overweight (http://www.nnc.gov.ph/plans-and-programs)
- 8.3% Filipino children ages 10-19 are overweight Human Nutrition. Johns Hopkins: Bloomberg School of
Public Health
(http://ocw.jhsph.edu/courses/humannutrition)
A Consumers Guide to the DRIs (Dietary Reference
Intakes). Health Canada. 2010-11-29.
INFOGRAPHIC: Whats the nutritional status of Filipinos?
(http://www.rappler.com/move-ph/issues/hunger/63518-
nutritional-status-filipinos)
DPC Manual 2015 DPC Department, UERMMMCI

Figure 9. Average weight and height of Filipino adults aged 20

years old and above (2013)

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