Major Health Problems

Corneal ulcers Blindness Skin: Generalized dryness Diagnosis: Serum retinol levels ,20 ug/dL (WHO) Impression cytology Treatment: If with active eye lesion: 200,000 I.U. immediately 200,000 next day 200,000 I.U. within next 14 days Prevention: Vitamin A supplementation Pre-schoolers: 200,000 i.u. p.o. every 4-6 months < 1 year old =give dose IRON DEFICIENCY (IDA) Normal Hgb levels (WHO): 6 months- 6 years old 11 gms/dL 6.1 to 14 year old 12 g/dL Adult male 13 g/dL Non-lactating/nonpregnant female 12 g/dL Pregnant female 11 g/dL Lactating female 12 g/dL Causes: Blood Loss Demand of fetus and placenta Intestinal Parasitism Malaria Schistosomiasis Low intake of heme iron Signs and Symptoms: Pallor: most important clue Hgb <5 g/dL Irritability Anorexia Tachycardia Systolic murmur Lab: Decrease serum ferritin levels decrease Hgb microcytosis,hypochloremia, poikilocytosis Treatment: FeS04 6 mgs/kg/day Vitamin C =enhances absorption Diet : Heme iron is better absorbed Iodine DeficiencyDISORDER (IDD) Goiter compensatory mechanism. commonly affected. Female more

Protein-Energy Malnutrition (PEM) and Micronutrient Deficiencies (VAD,IDA,IDD)

1998 FNRI National Nutrition Survey Pre-Schoolers: 0.2% moderately underweight 5.4% stunted 7.2% wasted Schoolchildren 8.3% moderately underweight 5.8% stunted 8.7%wasted Highest prevalence is among 1 year old at 14.2% Prevalence rate of anemia for all age group is 30.6% 36 out of 100 children (35.39%) have moderate to severe IDD 1991 Survey 10 out of 100 (10. %) children aged 6 months to 6 years have VAD 3-4 out of 100 children (35. 39%) children have deficient to low serum Vit.A COMMON NUTRITIONAL DISORDERS Protein-Energy Malnutrition (PEM) Protein-Calorie Malnutrition -can be attributed to: lack of adequate food wrong beliefs and practices FACTORS AFFECTING NUTRITIONAL STATUS OF THE FILIPINO CHILD child blood and nutritional intake food and nutrition intake of household Food demand function Food Threshold Income Occupation Education of Mother Food prices child health status Child feeding practice Food supply function Food production Food supply available for consumption

Vitamin A Deficiency Sources of Vit. A: Animal: best source is liver Plants: Green leafy vegetables Breastmilk is a rich source of Vit.A Signs and Symptoms: Early symptom: nyctalopia or nightblindness First clinical sign: Xerosis conjunctivae Bitots spots Corneal xerosis/ xerophthalmia

Common in mountainous areas: Causes irreparable damage to fetal brain

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Goitrogenic Food -Cassava, cabbage, cauliflower, red skinned peanuts, bamboo shoots, carrots, radish Classification of Endemic Goiter Grade Description 0 gland not abnormally enlarged 14 gland enlarged but not visible with neck extended 13 gland enlarged and visible only with neck extended 2 goiter visible with head in normal position 3 goiter easily visible from a distance Epidemiology Criteria For Assessing Severity of IDD Median value (ug / L) Severity of IDD <20 Severe IDD 20-49 Moderate IDD 50-99 Mild IDD > 100 No deficiency Tx: mild Iodine deficiency + iodized salt iodine rich food iodine oil capsule (200 mgs. K iodate) Lipcodol 1 cc injection (lasts 3-4 years) Prevention: Breastfeeding Iron-rich food Avoid goitrogens Protein-Energy Malnutrition Protein-energy malnutrition (PEM), or proteincalorie malnutrition, is an energy deficit due to chronic deficiency of all macronutrients. It commonly includes deficiencies of many micronutrients. PEM can be sudden and total (starvation) or gradual. Severity ranges from subclinical deficiencies to obvious wasting (with edema, hair loss, and skin atrophy) to starvation. Multiple organ systems are often impaired. Diagnosis usually involves laboratory testing, including serum albumin. Treatment consists of correcting fluid and electrolyte deficits with IV solutions, then gradually replenishing nutrients, orally if possible. PEM In developed countries PEM: is common among the institutionalized elderly (although often not suspected) and

among patients with disorders that decrease appetite or impair nutrient digestion, absorption, or metabolism. In developing countries PEM affects children who do not consume enough calories or protein. PEM GRADING PEM is graded as: 1. mild 2. moderate or 3. severe. Grade is determined by calculating weight as a percentage of expected weight for length or height using international standards: normal. 90 to 110%; mild PEM... 85 to 90%; moderate 75 to 85%; severe..< 75%; Classification and Etiology PEM may be 1. primary or 2. secondary. Primary PEM: -is caused by inadequate nutrient intake. Secondary PEM: -results from disorders or drugs that interfere with nutrient use.

I. Primary PEM: Worldwide, primary PEM occurs mostly in children and the elderly who lack access to nutrients, although a common cause in the elderly is depression. It can also result from fasting or anorexia nervosa. Child or elder abuse may be a cause 3 COMMON FORMS of PEM: The form depends on the balance of nonprotein and protein sources of energy In children, chronic primary PEM has three common forms: 1. marasmus, 2. kwashiorkor, and 3. marasmic- kwashiorkor: a form with characteristics of both.

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Starvation is an acute severe form of primary PEM. 1. Marasmus (also called the dry form of PEM) causes weight loss and depletion of fat and muscle. In developing countries, marasmus is the most common form of PEM in children. 2. Kwashiorkor also called the wet, swollen, or edematous form Is associated with premature abandonment of breastfeeding, which typically occurs when a younger sibling is born, displacing the older child from the breast. So children with kwashiorkor tend to be older than those with marasmus. May also result from an acute illness, often gastroenteritis or another infection (probably secondary to cytokine release), in a child who already has PEM low percentage of breastfeeding wrong weaning practices low consumption of oil Treatment: Milk, sugar, oil A diet that is more deficient in protein than energy may be more likely to cause kwashiorkor than marasmus. Less common than marasmus, kwashiorkor tends to be confined to specific parts of the world, such as rural Africa, the Caribbean, and the Pacific islands. In these areas, staple foods (eg, yams, cassavas, sweet potatoes, green bananas) are low in protein and high in carbohydrates. In kwashiorkor, cell membranes leak, causing extravasation of intravascular fluid and protein, resulting in peripheral edema. 3. Marasmic kwashiorkor : is characterized by features of marasmus and kwashiorkor. Affected children have some edema and more body fat than those with marasmus. Starvation : is a complete lack of nutrients. It is occasionally voluntary (as in fasting or anorexia nervosa) but usually due to external factors (eg, famine, wilderness exposure). II. Secondary PEM: This type most commonly 1. results from disorders that affect GI function, 2. wasting disorders, and 3. conditions that increase metabolic demands eg,

infections, hyperthyroidism, Addison's disease, pheochromocytoma, other endocrine disorders, burns, trauma, surgery, other critical illnesses). In wasting disorders (eg, AIDS, cancer) and renal failure, catabolism causes cytokine excess, resulting in undernutrition. End-stage heart failure can cause cardiac cachexia, a severe form of undernutrition; mortality rate is particularly high. Wasting disorders can decrease appetite or impair metabolism of nutrients. Disorders that affect GI function can interfere with digestion (eg, pancreatic insufficiency), absorption (eg, enteritis, enteropathy), or lymphatic transport of nutrients (eg, retroperitoneal fibrosis, Milroy's disease). PATHOPHYSIOLOGY The initial metabolic response is decreased metabolic rate. To supply energy, the body first breaks down adipose tissue. However, later, visceral organs and muscle also are broken down and decrease in weight. Loss of organ weight is greatest in the liver and intestine, intermediate in the heart and kidneys, and least in the nervous system. SYMPTOMS AND SIGNS: Symptoms of moderate PEM can be constitutional or involve specific organ systems. Apathy and irritability are common. The patient is weak, and work capacity decreases. Cognition and sometimes consciousness are impaired. Temporary lactose deficiency and achlorhydria develop. Diarrhea is common and can be aggravated by deficiency of intestinal disaccharidases, especially lactase (see Malabsorption Syndromes: Etiology). Gonadal tissues atrophy. PEM can cause amenorrhea in women and loss of libido in men and women. Wasting of fat and muscle is common in all forms of PEM. In adult volunteers who fasted for 30 to 40 days, weight loss was marked (25% of initial weight). If starvation is more

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prolonged, weight loss may reach 50% in adults and possibly more in children. Wasting (called cachexia in adults) is most obvious in areas where prominent fat depots normally exist. Muscles shrink and bones protrude. The skin becomes thin, dry, inelastic, pale, and cold. The hair is dry and falls out easily, becoming sparse. Wound healing is impaired. In elderly patients, risk of hip fractures and decubitus ulcers increases

and adolescents, child abuse and anorexia nervosa should be considered. Physical examination findings can usually confirm the diagnosis. Laboratory tests are required to identify causes of secondary PEM. Measurement of plasma albumin, total lymphocyte count, CD4+ T lymphocytes, and response to skin antigens may help determine the severity of PEM (see Table 3: Undernutrition: Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition )or confirm the diagnosis in borderline cases. Measurement of C-reactive protein or soluble interleukin-2 receptor should be measured when the cause of undernutrition is unclear ; these measurements can help determine whether there is cytokine excess. Many other test results may be abnormal: eg, decreased levels of hormones, vitamins, lipids, cholesterol, prealbumin, insulin (HUMULIN NOVOLIN) growth factor-1, fibronectin, and retinol-binding protein. Urinary creatine and methylhistidine levels can be used to gauge the degree of muscle wasting. Because protein catabolism slows, urinary urea level also decreases. These findings rarely affect treatment. Table 3. Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition Measurement: Normal ---------------------- 90110 (%) Mild Malnutrition------------8590 (%) Moderate Malnutrition ----7585 (%) Severe Malnutrition -------<75 (%) Body mass index Normal ------------------------ 1924* Mild Malnutrition------------1818.9 Moderate Malnutrition ----1617.9 Severe Malnutrition ------- < 16 Serum albumin (g/dL) Normal-----------3.55.0 Mild---------------3.13.4 Moderate--------2.43.0 Severe---------< 2.4 Serum transferrin (mg/dL) Normal-----------220400 Mild---------------201219 Moderate--------150200 Severe-----------< 150 Total lymphocyte count (per mm3) Normal--------------20003500

With acute or chronic severe PEM, heart size and cardiac output decrease; pulse slows and blood pressure falls. Respiratory rate and vital capacity decrease. Body temperature falls, sometimes contributing to death. Edema, anemia, jaundice, and petechiae can develop. Liver, kidney, or heart failure may occur. Cell-mediated immunity is impaired, increasing susceptibility to infections. Bacterial infections (eg, pneumonia, gastroenteritis, otitis media, UTIs, sepsis) are common in all forms of PEM . Infections result in release of cytokines, which produce anorexia, worsen muscle wasting, and cause a marked decrease in serum albumin levels. Marasmus in infants causes hunger, weight loss, growth retardation, and wasting of subcutaneous fat and muscle. Ribs and facial bones appear prominent. Loose, thin skin hangs in folds.

Kwashiorkor is characterized by peripheral

edema. The abdomen protrudes, but there is no ascites. The skin is dry, thin, and wrinkled; it can become hyperpigmented and fissured and later hypopigmented, friable, and atrophic. Skin in different areas of the body may be affected at different times. The hair can become thin, reddish brown, or gray. Scalp hair falls out easily, eventually becoming sparse, but eyelash hair may grow excessively. Alternating episodes of undernutrition and adequate nutrition may cause the hair to have a dramatic striped flag appearance. Total starvation is fatal in 8 to 12 wk. Thus, certain symptoms of PEM do not have time to develop. be apathetic but become irritable when held. DIAGNOSIS Diagnosis can be based on history when dietary intake is markedly inadequate. The cause of inadequate intake, particularly in children, needs to be identified. In children

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Mild------------------15011999 Moderate-----------8001500 Severe--------------< 800 Delayed hypersensitivity index Normal---------2 Mild-------------2 Moderate------1 Severe---------0 In the elderly, BMI < 21 may increase mortality risk. Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 = < 0.5 cm, grade 1 = 0.50.9 cm, grade 2 = 1.0 cm. Other laboratory tests can detect associated abnormalities that may require treatment. Serum electrolytes, BUN, glucose, and possibly levels of Ca, Mg, phosphate, and Na should be measured. Levels of blood glucose and electrolytes (especially K, phosphate, Ca, and Mg and occasionally Na) are usually low. BUN is often low unless renal failure is present. Metabolic acidosis may be present. CBC is usually obtained; normocytic anemia (usually due to protein deficiency) or microcytic anemia (due to simultaneous iron deficiency) is usually present. Stool cultures should be obtained and checked for ova and parasites if diarrhea is severe or does not resolve with treatment. Sometimes: urinalysis, urine culture, blood cultures, tuberculin testing, and a chest x-ray are used to diagnose occult infections because people with PEM may have a muted response to infections. PREVENTION AND TREATMENT Worldwide, the most important preventive strategy is to reduce poverty and improve nutritional education and public health measures.

Mild or moderate PEM, including brief

starvation, can be treated by providing a balanced diet, preferably orally. Liquid oral food supplements (usually lactosefree) can be used when solid food cannot be adequately ingested. Diarrhea often complicates oral feeding because starvation makes the GI tract more likely to move bacteria into Peyer's patches, facilitating infectious diarrhea. If diarrhea persists (suggesting lactose intolerance), yogurt-based rather than milk-based formulas are given because people with lactose intolerance can tolerate yogurt. Patients should also be given a multivitamin supplement Severe PEM or prolonged starvation requires treatment in a hospital with a controlled diet. The first priority is to correct fluid and electrolyte abnormalities (see Fluid and Electrolyte Metabolism) and treat infections. Next is to supply macronutrients orally or, if necessary, through a feeding tube, a nasogastric tube (usually), or a gastronomy (G) tube. Parenteral nutrition is indicated if malabsorption is severe (see Nutritional Support: Total Parenteral Nutrition (TPN)). Other treatments may be needed to correct specific deficiencies, which may become evident as weight increases. To avoid deficiencies, patients should continue to take micronutrients at about twice the recommended daily allowance (RDA) until recovery is complete. IN CHILDREN: Underlying disorders should be treated. For children with diarrhea, feeding may be delayed for 24 to 48 h to avoid making the diarrhea worse. Feedings are given often (6 to 12 times/day) but, to avoid overwhelming the limited intestinal absorptive capacity, are limited to small amounts (< 100 mL). During the first week, milk-based formulas with supplements added are usually given in progressively increasing amounts; after a week, the full amounts of 175 kcal/kg and 4 g of protein/kg can be given. Twice the RDA of micronutrients should be given, using commercial multivitamin supplements. After 4 wk, the formula can be replaced with whole milk plus cod liver oil and solid foods, including eggs, fruit, meats, and yeast. Energy distribution among macronutrients should be: about 16% protein, 50% fat, and

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34% carbohydrate. An example is a combination of powdered cow's skimmed milk (110 g), sucrose (100 g), vegetable oil (70 g), and water (900 mL). Many other formulas (eg, whole [full-fat] fresh milk plus corn oil and maltodextrin) can be used. Milk powders used in formulas are diluted with water. Usually, supplements should be added to formulas: - Mg 0.4 mEq/kg/day IM is given for 7 days; - B-complex vitamins at twice the RDA are given parenterally for the first 3 days, usually with vitamin A, - phosphorus, zinc, manganese, copper, iodine, fluoride, molybdenum, and selenium SELSUN (More in Mosby's Drug Consult) Because absorption of oral iron is poor in children with PEM, oral or IM iron supplementation may be necessary. Parents are taught about nutritional requirements IN ADULTS: Disorders associated with PEM should be treated. For example, if AIDS or cancer results in excess cytokine production, megestrol acetate or medroxyprogesterone may improve food intake. However, because these drugs dramatically decrease testosterone Trade Names DELATESTRYL in men (possibly causing muscle loss), testosterone DELATESTRYL should be replaced. Because these drugs can cause adrenal insufficiency, they should be used only short-term (< 3 mo). In patients with functional limitations, home delivery of meals and feeding assistance are key. An orexigenic drug, such as the cannabis extract dronabinol ARINOL, should be given to patients with anorexia when no cause is obvious or to patients at the end of life when anorexia impairs quality of life. Anabolic steroids have positive effects (eg, increase lean body mass, possibly improve function) in patients with cachexia due to renal failure and possibly in elderly patients Correction of PEM in adults generally resembles that in children. For most adults, feeding does not need to be delayed; small volumes are given often. A commercial formula for oral feeding can be used. Nutrient supply should be given at a rate of 60 kcal/kg and 1.2 to 2 g of protein/kg.

If liquid oral supplements are used with solid food, they should be given at least 1 h before meals so that the amount of food eaten at the meal is not reduced Treatment of institutionalized elderly patients with PEM requires multiple interventions, including environmental measures (eg, making the dining area more attractive); feeding assistance; changes in diet (eg, use of food enhancers and caloric supplements between meals); treatment of depression and other underlying disorders; and the use of orexigenics, anabolic steroids, or both. The long-term use of gastrostomy tube feeding is essential for patients with severe dysphagia; its use in patients with dementia is controversial Increasing evidence supports the avoidance of unpalatable therapeutic diets (eg, low salt, diabetic, low cholesterol) in institutionalized patients because these diets decrease food intake and may cause severe PEM. Complications of treatment: Treatment of PEM can cause complications (refeeding syndrome), including: fluid overload, electrolyte deficits, hyperglycemia, cardiac arrhythmias, and diarrhea. Diarrhea is usually mild and resolves; however, diarrhea in patients with severe PEM occasionally causes severe dehydration or death. Causes of diarrhea (eg, sorbitol used in elixir tube feedings, Clostridium difficile if the patient has received an antibiotic) may be correctable. Osmotic diarrhea due to excess calories is rare in adults and should be considered only when other causes have been excluded. Because PEM can impair cardiac and renal function, hydration can cause intravascular volume overload. Treatment decreases extracellular K and Mg. Depletion of K or Mg may cause arrhythmias. Carbohydrate metabolism that occurs during treatment stimulates insulin) release, which drives phosphate into cells. caused by a prolonged QT interval. Hypophosphatemia can cause muscle weakness, paresthesias, seizures, coma, and arrhythmias. With parenteral feeding, phosphate levels should be measured regularly. During treatment, endogenous insulin (HUMULIN NOVOLIN More in Mosby's Drug Consult) may become ineffective, leading to hyperglycemia.

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Dehydration and hyperosmolarity can result. Fatal ventricular arrhythmias can develop, possibly PROGNOSIS: In children, mortality varies from 5 to 40%. Mortality rates are lower in children with milder PEM and those given intensive care. Death in the first days of treatment is usually due to electrolyte deficits, sepsis, hypothermia, or heart failure. Impaired consciousness, jaundice, petechiae, hyponatremia, and persistent diarrhea are ominous signs. Resolution of apathy, edema, and anorexia are favorable signs. Recovery is more rapid in kwashiorkor than in marasmus. Long-term effects of PEM in children are not fully documented. Some children develop chronic malabsorption and pancreatic insufficiency. Very young children may develop mild mental retardation, which may persist until at least school age. Permanent cognitive impairment may occur, depending on the duration, severity, and age at onset of PEM. In adults, PEM can result in morbidity and mortality (eg, progressive weight loss increases mortality rate by 10% for elderly people in nursing homes). Except when organ failure occurs, treatment is uniformly successful. In elderly patients, PEM increases the risk of morbidity and mortality due to surgery, infections, or another disorder. Recovery is more rapid in kwashiorkor than in marasmus. Long-term effects of PEM in children are not fully documented. Some children develop chronic malabsorption and pancreatic insufficiency. Very young children may develop mild mental retardation, which may persist until at least school age. Permanent cognitive impairment may occur, depending on the duration, severity, and age at onset of PEM. Key Recommendations for the General Population ADEQUATE NUTRIENTS WITHIN CALORIE NEEDS Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the

intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol. Meet recommended intakes within energy needs by adopting a balanced eating pattern, such as the U.S. Department of Agriculture (USDA) Food Guide or the Dietary Approaches to Stop Hypertension (DASH) Eating Plan.

Basic of a healthy diet 1. Balance- a diet consisting of Carbohydrate at 5060%, Protein at 10-15% maximum of 20% and Fats at 20- 30% of total calories. 2. Moderation- Dietitian help clients learn to plan food portion sizes appropriately. - involves learning the distinct difference between hunger satisfaction and fullness. 3. Variation- All healthy diets involve the inclusion of several food-types, to obtain required amount of essential nutrients. Helps avoid food-boredom. * Source: WholeFitness.com Top 10 power foods: 1. Berries 2. Citrus 3. Vegetables 4. Whole grains 5. Salmon 6. Legumes 7. Nuts and seeds 8. Lean proteins 9. Tea 10. Olive oil

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DOH Comprehensive Nutrition Program General Objective: Reduction of morbidity and mortality rates due to avitaminosis and other nutritional deficiencies. Program Strategies: Standard Nutrition Intervention Program 1. Food and Micronutrient Supplementation Cereal legume blend BP5 Compact food Regular supplementation during consultation Universal Supplementation: ASAP Vitamin A capsule to 12 to 59 months old Iodine capsule to 15 to 40 years old female Iron tabs to pregnant women 2. Food Fortification National Salt Iodization Program Salt iodization Bill ( Asin Law ) R.A. 8172 Fortification of Value Rice Iron fortified Rice Project Flour Fortification with Vitamin A Sugar Fortification with Vitamin A Food Fortification: Educational approaches: -encourage breastfeeding diet WHO Guidelines: -measles -persistent, chronic diarrhea -respiratory tract infection -severe PEM -intestinal parasitism -pregnant female-Vit.A not 10,000 units per day,200,000 I.U.within 2 months after delivery -food products contain at least 1/3 of RDA B. Support Programs 1. Community Assessment Operation Timbang (OPT) IDD/VAD Prevalence Surveys 2. Training / Human Resource Development 3. Operations Research 4. Monitoring and Evaluation 5. Planning National Health Objectives by 2004 Goals: Prevalence rate of Protein-Energy malnutrition is reduced Vitamin A deficiency is eliminated as a public health problem Prevalence rate of iron deficiency anemia is reduced Iodine Deficiency Disorders is eliminated as a public health problem

Prevalence rate of overweight among preschoolers and prevalence rate of obesity among adults is reduced Health Status Objectives 1. Reduce the prevalence rate of protein-energy malnutrition Special Target 1993 Baseline 2004 Targets Population FNRI Neonates 4.9% 3.5% (0-28 days old) Infants (0-24 7.2% 6.25% months old) Preschoolers (25- 10.9% 9.0 % 59 months School age children (7-14 years old) a. Stunting 5.5 % 4.5 % b. Wasting 6.6% 4.6 % c. Moderately 7.4% 5.6% underweight Women and mothers a.Pregnant 21.3% 20% b. Lactating 12.8% 11.0% 2. Reduce the prevalence rate of Vitamin A Deficiency Special Target 1993 Baseline 2004 Targets Population (FNRI) Preschoolers 0.4% 0% (6 mths-6 yrs old) Women and mothers a. Pregnant 0.5% 0.2% b. Lactating 1.0% 0.3% 3. Reduce the prevalence rate of Anemia Special Target 1993 Baseline Population FNRI Neonates (0-28 8.7% days old) Infants (0-24 49.2% months old) Preschoolers (25- 26.7% 59 months) School age 30.8% children (7-14 yrs) Women and mothers a.Pregnant 43.6% b. Lactating 43.0% Older Persons 45.6% (60 yrs & older) Iron Deficiency 2004 Targets 6.0% 38.1% 20.0 % 20.4%

33.7% 33.3 38.O%

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4. Reduce the prevalence rate of iodine deficiency disorders (IDD) Special Target 1993 Baseline 2004 Targets Population FNRI School age children (7-14 yrs) 0.6% 20.4% A. Males 4.5% B. Females Older Women and mothers a.Pregnant b. Lactating 49.9% 42.2 38.O% 32%

10.Increase the level of awareness on healthy diet and maintenance of desirable body weight (Baseline is established in 2000) 11.Increase the proportion of overweight and obese seeking dietary counselling and practicing prescribed diet restriction. (Baseline data is established in 2000) 12.Increase the level of awareness on food safety. (Baseline data is established in 2000) SERVICE AND PROTECTION OBJECTIVES 1. Institutionalize nutri-clinic as part of health facilities. (Baseline data is established in 2000) 2. Increase the proportion of moderately and severely underweight children without medical complications rehabilitated at mothercraft centers or weighing posts to 15%.(Baseline 10.7% in 1997, FHSIS) 3. Increase the proportion of severely underweight children with medical complications referred to hospitals or nutri wards to 25%) 4. Increase the coverage of iron supplementation Special target 1998 baseline 2004 target popn (NS report) Infants (6-11 Baseline data is established in 2000 months) Pregnant women 64% 74% 5. Increase the coverage of Vitamin A supplementation among 12- to 59-month old children to 100 %. (Baseline :90% in 1998) FETP Survey Food Fortification Project Strategic Plan of the DOH -Micronutrient deficiency is one of the major health problems in the Philippines particularly vitamin A, iron, and iodine deficiencies. To address this problem the Philippines has embarked on a three-pronged strategy of supplementation, nutrition education, and food fortification. Based on studies, food fortification is the most cost effective and sustainable strategy to address micronutrient supplementation. This 5-year Food Fortification Strategic Plan 2000-2004 in response for the need to fast track food fortification of staples and processed foods was developed by: -The United Nations Childrens Fund (UNICEF) - the United States Agency for International Development (USAID) and - the Asian Development Bank (ADB) Weaknesses in the present system :

5. Reduce the prevalence rate of overweight and obese among the popn Special Target Population 1993 2004 Baseline Targets FNRI Preschoolers (0-6 yrs old) 6.5% 5.3% Adults (20 years old and over) A. B. les Males Fema 14.3% 18.6% 12.3% 16.6%

Risk Reduction Objectives: 1. Increase the proportion of infants exclusively breastfed up to six months of age to 30%.(Baseline:20% in 1988,NDHS) 2. Increase the proportion of infants given complementary foods at about six months of age to 30% (Baseline: 60.9% in 1998, NDHS) 3. Increase the proportion of mothers or caregivers taking their children to weighing posts, mothercraft centers, or health facilities (Baseline data is established in 2000) 4. Increase the percentage of individuals practicing healthy diet to 50 % ( Baseline:30.7% in 1995, Exploratory Survey on Healthy Diet) 5. Reduce the percentage of individuals eating junk foods to 50% (Baseline:81.3% in 1995, Exploratory Survey on Healthy Diet) 6. Reduce the percentage of individuals eating fast foods to 50% (Baseline: 79.3% in 1995 Exploratory Survey on Healthy Diet.) 7. Increase the percentage of individuals consuming green leafy and yellow vegetables to 100%.( Baseline: 87.6% in 1995 , Exploratory Survey on Healthy Dept ) 8. Increase the percentage of the individuals consuming foods rich in protein, vitamin A, iron, and iodine (Baseline data is established in 2000) 9.Achieve 100% universal salt iodization.( Baseline: 10% in 1998,NS Report)

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-lack of govt understanding on the needs of the food industry for fortification -lack of clear policy due to the absence of empirical and scientific evidences -lack of research support -lack of monitoring system and -weak advocacy and promotion of the project Current program for micronutrient supplementation seen as a medium term solution to the problem involves: - twice yearly vitamin supplementation of pre-school children through the Garantisadong Pambata - Vitamin A supplementation of VAD cases postpartum women and risk cases for VAD , ie: measles, chronic diarrhea, acute respiratory infections and malnutrition,iodine supplementation to identified cases of goiter in endemic areas and women ages 15 to 40 years and iron supplementation of infants, pregnant and lactating women Issues related to the micronutrient supplementation program: - lack of supplements - lack of efficient delivery - high cost to the government and -sustainability Goal of the 5-year plan: - to make widely available vitamin A, iron, and iodine fortified foods that would contribute to an increase in the micronutrient intake by at least 50% of the RDA of the vulnerable groups (preschool children and women of reproductive age group) by 2004. The plan is to continue with the projects currently implemented as follows: -fortification of salt with iodine -hard flour with Vit A and iron -NFA rice with iron -sugar with Vitamin A -edible oil with Vitamin A and -processed foods with Sangkap Pinoy Seal particularly condiments with iron Food Fortification Management Team is managed by: - members from the Dept of Health - a team of consultants which would report to the DOH The 4 intervention activities of the Management Team: - technology and internal quality assurance - promotion and advocacy - legislation, policy and guidelines development - research, surveillance and external monitoring/quality assurance Dietary diversification through food production :

takes time since this involves behavioral change and depends on the economic status of an individual or a country. In the Philippines there is no integrated plan for nutrition education activities -Nutrition education activities are being implemented by different government agencies such as the DOH, National Nutrition Council , FNRI,and various non-governmental organizations such as Nutrition Council of the Philippines (NCP) Helen Keller International and ( HKI ) Barangay Integrated Development Assistance for Nutrition Implementation ( BIDANI)

Weaknesses in the present system :

-lack of govt understanding on the needs of the food industry for fortification -lack of clear policy due to the absence of empirical and scientific evidences -lack of research support -lack of monitoring system and -weak advocacy and promotion of the project Operation Timbang Objectives of Operation Timbang General: -To generate data for nutrition assessment, planning, management and evaluation of local nutrition programs Specific: 1. to locate families with preschoolers whose weight is below or above normal 2. To identify and quantify preschoolers with below and above the normal weights needing immediate assistance 3. To locate families with preschoolers with cleft palate or harelip 4. To detect growth faltering among infants and preschoolers as early as possible 5. To encourage parents or guardians or caregivers to have their preschoolers weighed regularly 6. To determine priority areas and individuals for local program implementation (e.g. food and/or micronutrient supplementation, livelihood program and others 7. To provide appropriate health and nutrition services to preschoolers whose weights fall below normal and 8. To assess the effectiveness of the local nutrition program Uses of the OPT:

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Data gathered by the OPT is used for nutrition assessment and local planning evaluation and education. Through OPT the magnitude of PEM, malnutrition and the incidence of cleft palate or harelip among preschoolers in the bgy/municipality/city/ region can be estimated. The incidence of cleft palate could be indicative of deficiencies in Biotin,B6(pyridoxin)Vitamin A, folic acid and zinc. At the barangay, preschoolers with weights below normal and who belong to the poor families can be identified and provided immediate intervention. At the national level, nutritionally depressed municipalities, cities, and provinces can be identified for targetting and planning purposes. As an evaluation tool results of OPT are used to assess the:

-Impact of the interventions -overall nutritional progress of the community and -efficiency of the local nutrition program Definition of Terms: Nutrition is the science of food and its relationship to health. Essential Nutrients: Nutrients that cannot be synthesized by the body and thus must be derived from the diet are considered essential. They include vitamins, minerals, some amino acids, and fatty acids. They are needed by the body for one or more of these functions: to provide heat and / or energy ; to build and repair tissues ; and to regulate life processes. Although nutrients are found chiefly in foods some can be synthesized in the laboratory like vitamins and mineral supplements or in the body through biosynthesis. Nonessential Nutrients: Nutrients that the body can synthesize from other compounds, although they may also be derived from the diet, are considered nonessential. Micronutrient: an essential nutrient required by the body in very small quantities recommended intakes are milligrams or micrograms

specific risk groups to improve its nutritional value. Sangkap Pinoy Seal Program- a strategy to encourage manufacturers to fortify processed food products with essential nutrients at levels approved by the DOH. The fundamental concept of the program is to authorize manufacturers to use the DOH seal of acceptance for processed foods after these products passed a set of defined criteria. The seal is a guide used by consumers in selecting nutritious foods. RDA- recommended dietary allowance; levels of nutrient intakes which are considered adequate to maintain health and provide reasonable levels of reserves in the body tissues of nearly all healthy persons in the population Staple food-basic food normally consumed by the general population on a daily basis,e.g. rice, flour, sugar, oil Undernutrition Lack of nutrients can result in deficiency syndromes. kwashiorkor pellagra) or other disorders Obesity and the Metabolic Syndrome: Obesity Excess intake of macronutrients can lead to obesity. Toxic: Excess intake of micronutrients can be toxic. Macronutrients: are required by the body in relatively large amounts Macronutrients constitute the bulk of the diet and supply energy and many essential nutrients. Carbohydrates, proteins (including essential amino acids) fats (including essential fatty acids), macrominerals, and water are macronutrients. Macronutrients (contd) Carbohydrates, fats, and proteins are interchangeable as sources of energy: fats yield 9 kcal/g (37.8 kJ/g); proteins and carbohydrates yield 4 kcal/g (16.8 kJ/g). Micronutrients are needed in minute amounts. Basic Nutritional Needs The Minimum daily recommended allowances o Calories 2700 o Protein 56 grams o Calcium 0.8 g

Fortification- the addition of nutrients to processed foods /products at levels above the natural state as an approach to control micronutrient deficiency, food fortification is the addition of micronutrient deficient in the diet to a food which is widely consumed by

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o o o o

Iron -

10 mg

o Vit. A - 5000 IU
Thiamine 1.4 mg Vit C 45 mg Riboflavin 1.6 mg Niacin - 18 mg

A well nourished person Possesses Abundant Vitality Bones are well formed Muscles well developed and strong Contour of body is pleasing Body functions efficiently Key Recommendations for Specific Population Groups People over age 50. Consume vitamin B12 in its crystalline form (i.e., fortified foods or supplements). Women of childbearing age who may become pregnant. Eat foods high in heme-iron and/or consume iron-rich plant foods or iron-fortified foods with an enhancer of iron absorption, such as vitamin C-rich foods. Women of childbearing age who may become pregnant and those in the first trimester of pregnancy. Consume adequate synthetic folic acid daily (from fortified foods or supplements) in addition to food forms of folate from a varied diet. Older adults, people with dark skin, and people exposed to insufficient ultraviolet band radiation (i.e., sunlight). Consume extra vitamin D from vitamin D-fortified foods and/or supplements. KEY RECOMMENDATIONS Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol. Meet recommended intakes within energy needs by adopting a balanced eating pattern, such as the USDA Food Guide or the DASH Eating Plan. Based on dietary intake data or evidence of public health problems, intake levels of the following nutrients may be of concern for: Adults: calcium, potassium, fiber, magnesium, and vitamins A (as carotenoids), C, and E, Children and adolescents: calcium, potassium, fiber, magnesium, and vitamin E,

Specific population groups (see below): vitamin B12, iron, folic acid, and vitamins E and D. At the same time, in general, Americans consume too many calories and too much saturated and trans fats, cholesterol, added sugars, and salt. Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Vitamins (Food and Nutrition Board, Institute of Medicine, National Academies) Life Stage group Infants 06 months Children 1-3 4-8 Males 9-13 14-18 19-30 31-50 51-70 >75 Life Stage group Infant s 0-6 month s Childr en 1-3 4-8 Vit A 400 300 400 600 900 900 900 900 900 Vit. C 40 15 25 45 75 90 90 90 90 Vit. D 5 3+ 5+ 0.9 1.0 1.1 1.1 1.1 1.1 Vit. E 4.0 6 7 0.9 1.0 1.1 1.1 1.1 1.1 Niaci n 2.0 Vit. K 2.0 30 37 12 16 16 16 16 16 Vit B 0.3 Pantot henic Acid 1.7 Bioti n 0.5

Thiami ne 0.2

Riboflav in 0.3

0.5 0.6

0.5 0.6

6 8

0.5 0.6

150 200

.9 1.2

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Obesity: Understanding Adult Obesity The Rising Rate of Childhood Obesity is Alarming 30% of children are overweight or at risk for overweight

WEIGHT MANAGEMENT To maintain body weight in a healthy range, balance calories from foods and beverages with calories expended. To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity. NUTRITIONAL GUIDELINES REVISED ED. 2000 FOR FILIPINOS

Engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight. To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week. For most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or longer duration. To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood: Engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements. To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with a healthcare provider before participating in this level of activity. Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.

Weight Control Information Network What is Obesity How is Obesity Measured Body Mass Index Body Fat Distribution Causes of Obesity Consequences of Obesity Who should lose weight How is Obesity treated

1. Eat a variety of foods everyday. 2. Breastfeed infants exclusively from birth to 4-6 months, then give appropriate foods while continuing breastfeeding. 3. Maintain childrens normal growth through proper diet and monitor their growth regularly. 4. Consume fish, lean meat, poultry or dried beans. 5. Eat more vegetables, fruits, and root crops. 6. Eat foods cooked in edible/cooking oil daily. 7. Consume milk, milk prod. or other calcium rich foods such as small fish and dark green leafy vegetables everyday. 8. Use iodized salt, but avoid excessive intake of salty foods. 9. Eat clean and safe foods. 10. For a healthy lifestyle and good nutrition, exercise regularly, do not smoke, and avoid drinking alcoholic beverages. PHYSICAL ACTIVITY

What is Obesity? to be very overweight OVERWEIGHT - Excess amount of body weight (muscles, bone, fat, water) OBESITY Excess amount of body fat Fats Energy storage Heat insulation Shock absorption Women more body fat Measuring Body Fat Underwater measurement

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Dual energy XRay Absorptiometry (DEXA) FAT Thickness Bio-Cutaneous Meter

Body Mass Index Formulae using patients weight and height BMI = weight (kg) / height (m) 2 BMI = 25 29.9 ( overweight ) = >30 ( obese) Body Fat Distribution Women collect fats in hips, buttocks Men collect fats in bellies Waist measurement women > 35 inches men > 40 inches Causes of Obesity Genetic factors: Environmental Factors Lifestyle behaviors Physical activity Psychological Factors Response to negative emotions Binge eating disorders o Depression / Low self-esteem Other causes Medical illnesses Hypothyroidism Cushings syndrome Depression Neurological problems Drugs Steroids Antidepressants Consequences of Obesity Health Risks Type 2 Diabetes Heart Disease Hypertension Stroke Cancer (colon, rectum, prostate, gallbladder, breast, uterus ,cervix, ovaries)

Psychological and Social Effects: Emotional suffering Prejudice / discrimination Feelings of rejection / shame / depression Other health problems Gallbladder disease and gallstones Liver disease Osteoarthritis Gout Pulmonary problems Reproductive problems Consequences of Obesity Health Risks Type 2 Diabetes Heart Disease Hypertension Stroke Cancer (colon, rectum, prostate, gallbladder, breast, uterus ,cervix, ovaries) Who should lose weight? *BMI 25-29.9 prevention of additional weight gain recommended Family History of Chronic Diseases Diabetes , Heart Disease Pre-existing Medical Condition Hypertension High Cholesterol High Sugar level Apple shape Treatment Depends on: Level of Obesity Overall Health Condition Motivation to Lose weight Modes: Diet Exercise Behavior Modification Weight losing drugs Surgery Treatment: DIET -Limit intake of food rich in cholesterol and saturated fats - Eat more fruits and vegetables

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- Reading labels is helpful. Choose food with low fat content. - Use cooking methods that require little or no oil. -Eat fish more often than meat or poultry -Limit intake of egg yolks to 3-4 times a week -Eat more of dried beans, peas and legumes -Eat more cereals and grains Treatment: EXERCISE -30-60 minutes of aerobic exercise 3-4 times a week -Increase physical activity at home and at work Treatment: DRUGS Top 10 Benefits of Being Active 1. Improve blood glucose management. Activity makes your body more sensitive to the insulin you make. Activity also burns glucose (calories). Both actions lower blood glucose.] 2. Lower blood pressure. Activity helps your heart pump stronger and slower. 3. Improve blood fats. Exercise can raise good cholesterol (HDL) and lower bad cholesterol (LDL) and triglycerides. These changes are heart healthy. 4. Take less insulin or diabetes pills. Activity can lower blood glucose and weight. Both of these may lower how much insulin or diabetes pills you need to take. 5. Lose weight and keep it off. Activity burns calories. If you burn enough calories, you'll trim a few pounds. Stay active and you'll keep the weight off. 6. Lower risk for other health problems. Reduce your risk of a heart attack or stroke, some cancers, and bone loss 7. .Gain more energy and sleep better. You'll get better sleep in less time and have more energy, too. 8. Relieve stress. Work out or walk off daily stress. 9. Build stronger bones and muscles. Weightbearing activities, such as walking, make bones stronger. Strength-training activities, such as lifting light weights (or even cans of beans), make muscles strong. 10. Be more flexible. Move easier when you are active. Nutrition and Disease Prevention Lowers Heart Disease Lowers High Blood Pressure Lowers Cancer Lowers Bone loss Increases Immune System Important numbers to remember:

Blood Pressure Increase in blood pressure increases heart workload heart enlarges heart weakens Salt restriction Caffeine reduction Lifestyle changes - exercise

Cholesterol Risk of heart disease increases as Cholesterol increases Good cholesterol HDL > 35 mg/dl Bad cholesterol LDL < 130 mg/dl Low fat, low cholesterol diet Fruits and vegetables 20-30 mins. Exercise - 3 days a week Supplements to Boost your Health Vitamin B12 needs stomach acid to be absorbed ** supplement form- No Acid needed Symptoms: Anemia Blood cell disorders Neurological disorders Changes in gait 2.4 microgr/day Folate ( Folic acid) B Vitamin that reduces levels of HomoCysteine Found in dark green, yellow and orange fruits and vegetables Beans, nuts, fortified grain products pasta and flour Spinach, orange juice and lentils Calcium and Vitamin D o 1,200 microgm/day o Calcium carbonate citrate o Skin main producer of Vitamin D o Elderly people 10 15 mg/ day DIETARY SUPPLEMENTS ARE NOT DIETARY SUBSTITUTES

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