Nutrition and Adequate diet

Adequate diet:
A mixture of food stuffs selected to satisfy the nutritional requirements of the body in quality and quantity. It should be safe and of good taste and smell. It should be suitable for weather age, effort and physiological status of every one.

1. Dr. Dalia El-Shafei
Assoc. prof., Community Medicine Department, Zagazig University
http://www.slideshare.net/daliaelshafei

2. LEARNING OBJECTIVES:
Identify sources, functions, effect of deficiency of nutrients.
Understand the characteristics of adequate, balanced diet.
Develop a diet plan by using the dietary guides and nutritional pyramid.
Describe diets for vulnerable groups.
Understand the causes, manifestations and control of malnutrition problems.
Explain methods of assessment of nutritional status.
Describe diet plans for selected chronic diseases (therapeutic diet).

3. FACTORS AFFECTING ENERGY
REQUIREMENTS

4. FACTORS AFFECTING ENERGY REQUIREMENTS
Physical activity
•Type & duration of activity and
size of the person.
Lean body mass (LBM)
•↑LBM →↑Metabolic activity
→↑Energy requirements.
Age
•↑BMR & energy requirements
during periods of growth then ↓at
older age.
Climate
•↑Energy requirements in low
atmospheric temperature to
maintain body temperature.
Fevers
•↑BMR by 7% for each ↑0.83°C in
body temperature.
Pregnancy & lactation
•↑BMR & energy requirements.

5. ESTIMATION OF ENERGY REQUIREMENTS
BMR
•1.0 K.cal/kg BW
/h (for men)
•0.9 K.cal/ kg BW
/h (for women)
•BMR/day = 1.0 or
0.9 x BW x 24
Physical activity
requirements
•Sedentary life =
20% of BMR
•Very light activity
= 30% of BMR
•Moderate activity
= 40% of BMR
•Heavy activity =
50% of BMR
Specific dynamic
action of food
(S.D.F)
•Energy needed for
digestion
absorption &
metabolism of
food) = 10% of
BMR.
Energy requirements = BMR + Phys. Activity + S.D.F.

6. THE GLYCEMIC INDEX AND
GLYCEMIC LOAD

7. Aservingofahigh-fiberfood,suchasbackedbeans
resultsinlowerbloodglucoselevelscomparedtothe
sizeservingofmashedpotatoeswhichresultsina
higherbloodglucoselevel.
Whyareweconcernedwiththeeffectsofvariousfoods
onbloodglucose?Foodsthatresultinahighblood
glucoselevelelicitalargereleaseofinsulinfromthe
pancreaswhichchronicallywillleadtomanybad
effectsonthebody.

8. Twofoodmeasurementshavebeendevelopedwhichare
usefulinpredictingthebloodsugarresponsetovarious
foodsandindietplanningtoavoidhyperglycemia.

9. GLYCEMIC INDEX (GI)
Itisameasureofhowquicklyfoodsthatcontain
carbohydrateraisebloodglucoselevels.
Somefoodscausearapidriseinbloodglucose(withahigh
GI)whileotherscauseagradualrise(withalowGI).
Thisdependsonstarchstructure,fibercontent,food
processingandotherfoodcontentsasfat.

12. GLYCEMIC LOAD (GL)
•Anotherwayofdescribinghowdifferentfoodsaffect
bloodglucoselevels
•More useful because it considers the glycemic index &
the amount of carbohydrate consumed. Glycemic load = Glycemic index X Grams of CHO serving /100

14. RANGE OF GLYCEMIC INDEX AND GLYCEMIC LOAD:

15. ADEQUATE DIET

16. Amixtureoffoodstuffsselectedtosatisfythenutritional
requirementsofthebodyinqualityandquantity.
Itshouldbesafeandofgoodtasteandsmell.
Itshouldbesuitableforweatherage,effortand
physiologicalstatusofeveryone.

17. DIETARY GUIDELINES
Everyday,foodmustcontainallnutritionalelements(alllevels
oftheguidepyramid).
Eatnutritionallyadequatefood“Varietyoffoods;20%oftotal
caloriesfromproteins,25%fromfats&therestfrom
carbohydrates(55%)”.
Drinkplentyofwater.
Don'teatbetweenmeals(snackingonlybyfruits&vegetables).
Eat5-6smallmealsinsteadof3hugemeals&last-mealmust
bebefore9PM.

18. DIETARY GUIDELINES
↓Salt&refinedsugarsintake(whitepoisons).
↓Intakeofcanned,preserved,smokedandsaltedfoods.
Checkforexpireddatesforcanned&frozenfoodsanddonot
eatnutsstoredforlongperiods(containaflatoxin).
↑Consumptionoffreshfruits&greenleafyvegetables.
↓Intakeofready-madefoods(fastfoods)andtoomuch
processedfoods“fullofsaturatedfats&cholesterol”.

19. DIETARY GUIDELINES
↑Consumptionofdietaryfibers&complex
carbohydrate(wholegrainbread).
↑Consumptionofcalciumcontainingfoods
(greenleafyvegetable,fishwithbonesandmilk).
↓Consumptionoftotalfatsespeciallysaturated
fatsandcholesterolcontainingfoods.
Usevegetableoilsinsteadofmargarine(trans-
fats)forcooking

20. THE HEALTHY EATING PLATE

21. In(2011)theNutritionalGuidePyramidwasreplacedwithanew
andsimplericon,MyPlate.Itisbasedonhowourfood,drink,and
activitychoicesaffectourhealth.

22. Makemostofyourmeal
vegetables&fruits–½of
yourplate:
•Aimforcolorandvariety
•Potatoesdon’tcountasvegetables
becauseoftheirnegativeimpacton
bloodsugar”.
Goforwholegrains–¼of
yourplate:
•Wholeandintactgrains—whole
wheat,barley,oats,brownrice,and
foodsmadewiththem,
•Mildereffectonbloodsugar&
insulinthanrefinedgrains.
Proteinpower–¼ofyour
plate:
•Fish,chicken,beans,andnuts.
•Limitredmeatandavoidprocessed
meatssuchashamburgerand
sausage.
Healthyplantoils–in
moderation:
•Healthyvegetableoilslikeolive,
canola,soy,corn,sunflower,peanut
•Avoidpartiallyhydrogenatedoils
“containunhealthytransfats”.
•Low-fatdoesNotmean“healthy.”
Drinkwater,coffee,ortea:
•Skipsugarydrinks
•Limitmilk&dairyproductsto1-2
servingsperday
•Limitjuicetoasmallglassperday.
Stayactive:
•Theredfigurerunningacrossthe
HealthyEatingPlate’splacematisa
reminderthatstayingactiveisalso
importantinweightcontrol.

24. ARE THE RELATIVE SIZES OF THE HEALTHY EATING PLATE
SECTIONS BASED ON CALORIES OR VOLUME?
TheHealthyEatingPlatedoesnotdefineacertainnumberofcaloriesorservings
perdayfromeachfoodgroup.
Therelativesectionsizessuggestapproximaterelativeproportionsofeachof
thefoodgroupstoincludeonahealthyplate.
Theyarenotbasedonspecificcalorieamounts,andtheyarenotmeantto
prescribeacertainnumberofcaloriesorservingsperday,sinceindividuals’
calorieandnutrientneedsvarybasedonage,gender,bodysize,andlevelof
activity.

25. NUTRITION OF VULNERABLE
GROUPS

26. Nutritionplaysamajorrolethroughouteachstageofthelifecycle.
Therearenutritionallyvulnerablegroupswhoareatriskdueto
increasedphysiologicalneedstocertainnutrients.
Infants &
preschool
children.
School
children.
Adolescents. Pregnant(s)
&
lactating(s).
Elderly
group.

27. NUTRITIONAL DAILY, REQUIREMENTS OF VULNERABLE
GROUPS
NutrientInfantsAdolescentsPregnantLactatingElderly
Energy110 kcal/kgm3600 kcal (boys)
2600 kcal (girls)
2800 kcal 3200 kcal 1800 kcal
Protein 2-3 gm/kg 1 gm/kg 2-3 gm/kg 3 gm/kg 1 gm/kg
Vit. A 375 µgm 1000 µgm 800 µgm 1300 µgm 800 µgm
Vit. D 10 µgm 10 µgm 10 µgm 10 µgm 10 µgm
Vit. C 30 mg 60 mg 70 mg 95 mg 60 mg
Calcium 240 mg 1300 mg 1200 mg 1200 mg 1200 mg
Iron 8 mg 15 mg 30 mg 15 mg 10 mg
Iodine 50 µgm 150 µgm 175 µgm 200 µgm 150 µgm
Zinc 5 mg 15 mg 15 mg 19 mg 15 mg
Folic acid 30 µg 200 µg 400 µg 280 µg 180 µg

28. FEEDING OF INFANTS “BREAST FEEDING”
Advantages of breast milk
•Secreted in the first 3-4 days in small amount.
•High contents of carotene, maternal antibodies, digestible proteins, less sugar and fat and
more sodium, potassium and chloride.
Colostrum
•Rich in proteins, vitamins, mineral, IgA and galactolipid(for brain growth).
•Contains hormones, growth factors & anti-bacterial factors as lysozymes, macrophages.
•Contains lactoferrinwhich binds iron for absorption and prevents bacterial multiplication.
•It is bacteriologically safe, ready made, sterile always fresh and of suitable temperature.
•Its amount regulated by baby suckling according to his need.
•It reduces risk of infections, allergy and obesity of infants.
Mature breast milk

29. Advantages of breast-feeding process
Has good psychological
effect on baby & mother and
initiating early mother baby
bonding.
Promotes development of
jaws, teeth and speech
pattern of baby.
Helps uterine involution.
↓ Risk of post partum
hemorrhage.
↓ Risk of cancer breast &
ovarian cancer.
Easier for mother and saves
her money that paid in bottle
feeding.

30. Requirements of breast feeding
After birth
•Startasearlyaspossibletostimulatemilk
secretion.
1
st
6 months •Exclusive"Nootherfood”.
After 6
th
month
•Weaningstartedbyintroductionofotherfoods
withbreastmilk
•Tofacetherapidgrowth&developmentofbaby
andcompensatesomedeficientnutrientsinmilk
asiron.
•Startiswithfluids,semisolidandsolidfoods.
•Usespoonorcupnotbottlebeforebreast
feeding.
•Ifdiarrheaoccurs,stopthisfoodandreplaceby
anothergradually.

31. FEEDING OF PREGNANT & LACTATING MOTHERS
They need more nutritional elements because of:
Growth of the
fetus &
placenta.
↑Mother
weight.
↑BMR. Production of
milk.

32. FEEDING OF PRESCHOOL & SCHOOL CHILDREN
Characterizedby
rapidgrowth&
development.
↑Needoffoodrich
inproteins,calcium,
iron,vit.D,vita.C,
vit.Bcomplexand
calories.

33. FEEDING OF ADOLESCENTS
During adolescence
period body mass ↑
by 35% in boys &
20% in girls.
Dramatic physical,
biochemical and
emotional changes.

34. FEEDING OF THE ELDERLY
↓Requirements of all nutrients
due to ↓BMR, & ↓activities.

35. ASSESSMENT OF THE
NUTRITIONAL STATUS

36. Methods of Nutritional Assessment
Relevant data
Food data
Availability
Prices
Production
Importation
Vital indices
Morbidity rates
Mortality rates
Investigation of the nutritional status
National food
consumption
Dietary surveyHealth appraisal
Dietary history
Medical history
24-hours recall
Clinical
examination
Anthropometric
measurements
Weight & height
Skin fold
thickness
Mid-upper arm
circumference
Waist
circumference
Laboratory
investigations
Blood Hg
Serum or urine
Stool analysis
Physiological
tests

37. Food data
Availability Prices Production Importation
Vital indices
Morbidity
rates
Diarrheal
diseases among
children
L.B.W.
Parasitic
infestations
T.B.
Mortality rates
Stillbirth
Perinatal
mortality
Neonatal
mortality
Infant &
preschool
mortality rates
Relevant data

38. National food
consumption
Dietary survey Health appraisal
Dietary
history
Medical
history
24-hours
recall
Clinical
examination
Anthropometric
measurements
Weight &
height
Skin fold
thickness
Mid-upper
arm
circumference
Waist
circumference
Laboratory
investigations
Blood Hg
Serum or
urine
Stool analysis
Physiological
tests
Investigation of the
nutritional status

39. NATIONAL FOOD CONSUMPTION
For estimation of the average food consumption (the
national diet) the food-balance sheet technique is used.

41. Food balance sheet technique
Aim
•Determiningtheindividualsharefromdifferentfoodsassuming
thattheavailablefoodsaredistributedequallyamongthe
population.
•Itisusedforthecommunityasawhole
Steps
•Thedifferentfoodsaredividedinto“11”similargroupsas
cereals,starchyroots,pulsesandlegumes,sugarandhoney,fresh
vegetables,fruits,meatandpoultry…etc.
•Calculationoflocalproductionofthesefoodgroupsplusthe
amountoffoodsimportedordonated.
•Fromtheabovecalculationasubtractionoftheamountoffood
exportedplusthatnotusedbyhumanbeings(not-edible)isdone.
•Thedifferenceiscalledthe“Balance”whichistheamount
consumedbythepopulation.ItisthendividedbyNo.of
populationandby360togettheindividualshareingramsfrom
thenationalfoodsperday.

42. Theconsumptionofdifferent
fooditemsasmilk,meat,eggs
….etcareanalyzedintotheir
nutrientsandenergytogivethe
individualconsumptionof
eachnutrient(asprotein,fats,
vitamins,iron…etc)and
energyperday.

43. Advantages
•Exploresthenationalfood
consumption&themaindefects
init.
•Usedtocomparebetweenaverage
foodconsumptioninsuccessive
yearstoshowthetrendof
consumption.
•Usedtocomparebetweendifferent
countries.
•Byusingit,wecanidentifythe
mainsourcesofdifferent
nutrientsinthenationaldietas
protein&ironcontentsinEgyptian
dietaremainlyfromplantsources.
Disadvantages
•Assumesthatthefoodis
distributedequallythroughoutthe
yearamongthepopulationwhichis
nottrueduetodifferentsocio-
economicconditionsandseasons.
•Ignores differences in
requirementsofpeopleregarding
age,sex,occupation,physical
activity…etc.

44. Pattern of food consumption
in Egypt
Cereals (especially bread) & legumes form the main bulk of diet.
“Supply the greater part of energy, proteins, iron, vit. B & fibres”
Energy is in excess than required (high carbohydrates & fats).
The protein content is mainly from the plant sources (low
biological value).
Moderate consumption of vegetables & fruits.
Low consumption of meat, milk & eggs.
Iron intake is high but mainly from plant sources (cereals) which
is of low absorbability.

45. Impact on nutritional status of Egyptians
Iron & B12
deficiency anemias
Protein deficiency
among children
Obesity

46. DIETARY SURVEY
•Carriedouttofindoutifthefoodintakesatisfiestheindividuals’
requirements.
•Canbedoneonindividualsorhomogenousgroups(families,camps,
patientsinahospital)providedthatthesegroupsofpopulationeatfrom
acommonkitchen.Itismorepreciseandfeasible.
•Allfoodsusedinpreparingmealsareweighingeverydaywith
subtractingtheunusedpartsandwastes.Theactualamountoffood
whicheaten/dayarecalculatedforaspecialperiod(oneweek)then
theendamountdivided/No.ofindividualsinthegroup/No.ofdays
(7)togettheactualindividualshareinfoodconsumption/day.
The method

47. Limitations
•Concernedwithwhat
peopleareeatingwhich
consideredaprivate
issue.
•Itsoccurrencebyitself
might involuntarily
changethepatternof
foodconsumption.
Advantages
•More accurate&
feasible(representsthe
foodactuallyeaten).
•Suitablefornutritional
experimentatione.g.,to
testvariationsindietor
theeffectofintroduction
ofnewfoods.

48. HEALTH APPRAISAL (COMPREHENSIVE CLINICAL
EXAMINATION)
Health
appraisal
Dietary
history
Medical
history
24-hours
recall
Clinical
examination

49. Dietary
history
•Comprehensivenutritionalinterview
todetectlivingconditions,habits,culture
andeconomic&psychologicalfactors...
etc.
Medical
history
•Malnutrition,parasitic&chronic
diseases.
24-hours
recall
•Simple&cheapmethod“Recallofall
foodsconsumedthepreviousdaytothe
testbutitisnotsuitableforold
persons”.

50. HEALTH APPRAISAL
(COMPREHENSIVE CLINICAL EXAMINATION)
Itisdonetodetectphysicalsignsofnutritionaldeficiency.
However,thiswillbesomewhatlateasagainsteverycase
showingfrankclinicalmanifestationsatleastthereare
“10”casesinthesubclinical(biochemicalorfunctional)
stages.

51. Defect in body functions and frank manifestations of malnutrition
Detected by clinical examination and anthropometric measurements.
↓Enzymatic activity and physiological functions
Detected by biochemical and physiological testing
↓Plasma levels of some nutrients
Detected by biochemical testing
↓Food intake or ↑loss
Detected by dietary history, survey.
Effect of nutritional deficiency passes into stages:

52. Skin,hair&nails
•Todetectmanifestationsofvit.A,
B1,B3&proteindeficiencies
Head&neck
•Todetectsignsofiron,Ca,
iodine,vit.B2,C&fluorine
deficiencies.
Muscles&skeletalsystem
•TodetectP.E.M.&rickets
manifestations.
Nervoussystem
•Todetectsignsofvit.B1,B3,
B12&Cadeficiencies.
Cardiovascularsystem
•Todetectvit.B1deficiency.

53. Clinicalsigns&symptomsarenotoftenspecific.
Bodycanadapttoverylowintakeespeciallywith
sufficientbodystores.
Clinicalsignstakelongperiodtobemanifested
“youngwomenhavingdeficientintakeofCa&vita.D
oftensuffersnoilleffectsinyoungage,buttheyface↑
riskofosteoporosisaftermanyyears”.
Limitations of clinical examination method:

54. Anthropometric measurements
Weight &
height
Skin fold
thickness
Mid-upper
arm
circumference
Waist
circumference

55. Weight & height
Theyareusedmainly
toevaluatenutritional
statusofchildren.
Eachofthemis
plottedongrowth
chartsagainstagefor
growthmonitoring.

56. Height for age
•<5
th
percentileofthe
referencepopulation
→Stuntedchild
(shortforage)in
chronic under-
nutrition.
Weight for height
•<5
th
percentileof
the reference
population →
Wastedchild(thin
forage)inacute
under-nutrition.
Weight for age
•<5
th
percentileofthe
referencepopulation
→Underweightchild
forageinbothacute
&chronicunder-
nutrition.
WHO indices for growth monitoring of children:

58. Preschool
children
in Egypt
Stunted
Wasted
Under-weight

59. Body Mass Index (BMI)(Quetelet's index):
Good measure of overweight not obesity as weight may increase due to
excess muscularity or oedema not always due to excess fat deposition.

60. Skin fold thickness (S.F.T.)
Skinthicknessovermid-
tricepsormidbiceps
musclesorsubscapular
orsuprailiacregionsare
measuredbycertain
caliberinmillimeters.
Itisusedininfants&
childrentoassessobesity
(fatdeposition).

62. Mid-upper arm circumference (MUAC)
Measuringthecircumferenceofmid-nondominantupperarmby
usingnon-stretchabletape.
Readingsaremeasuredincentimetersandcomparedwithstandard
referencetables.
ItprovidesagoodmeasureofthesubcutaneousfatreserveasS.F.T.

64. Waist circumference
Should not exceed 88cm for females & 102 cm for males.
Waist hip ratio (WHR): Should be <1, if above denotes android obesity.

65. Laboratory investigations
Blood Hg
Detection of iron
deficiency anemia
Serum or urine
Assess the level of the different nutrients
“amino acids, serum retinol, iodine,
some vitamins & alkaline phosphatase
enzyme level to diagnose vit. D
deficiency”
Stool analysis Intestinal parasites
Physiological
tests
Dark adaptation test &
muscle activity test

66. THESE METHODS OF ASSESSMENT CAN BE USED:
On the community level
•Nationalfoodconsumption
method.
•Dietarysurvey.
•Relevantdata&vitalindices.
On the individual's level
•Dietarysurvey.
•Clinicalhealthappraisal.
•Anthropometricmeasurements.
•Laboratoryinvestigations.