Dasar-dasar gizi

masyarakat
Dr. joko wahyu wibowo MKes

Nutritional Status:
(status gizi=keadaan gizi)

Keadaan

tubuh sebagai akibat dari

keseimbangan antara konsumsi dan
pemanfaatan zat gizi.
Normal vs malnutrition.

Community nutritional
assessment
To

map out the magnitude and

geographical distribution of
malnutrition
Discover and analyze the ecological
factors that directly or indirectly
responsible
Suggest appropriate corrective
measures
Preliminary step for further action

Malnutrition
A pathological state resulting from a relative or absolute
deficiency or excess of one or more essential nutrients.
Overnutrition
Undernutrition
Specific deficiency
Imbalance

Overnutrition
resulting from the
consumption of an
excessive quantity
of food, over an
extended period of
time

Undernutrition
resulting

from the
consumption of an
inadequate quantity
of food, over an
extended period of
time

Penyebab Gizi Kurang

Kurang Gizi
Penyebab
langsung

Penyebab tak
langsung

Infeksi

Asupan gizi

Pangan tak
cukup

Pola asuh tak

memadai

Yan Kes.
dan sanitasi
Tak memadai

Pendidikan, Pengetahuan dan ketrampilan rendah

Masalah di
masyarakat

Pemberdayaan
SDM kurang
Pengangguran, Inflasi, kurang pangan dan kemiskinan

Akar masalah

Situasi Pol EK Sos

Epigenetic Inheritance
Genetic

tags are
passed down
through generations
When the zygote is
formed many
epigenetic tags are
removed from the
chromosomes of the
parents, but some
remain

Epigenetic Inheritance cont.

Previously

believed
that genetic
information was
passed through DNA
only
Studies in the field of
epigenetics shows
that parents
experiences are
passed on to offspring
through epigenetic
tags

Environment &Epigenome

Mounting evidence
suggests that
fetuses are
surprisingly
susceptible to
outside influences
such as
environmental
pollutants,
pesticides, and other
toxins.

Agouti Twin Sisters

Coat color serves as a sensor

for the degree of methylation present

Contrasting phenotypes

duplication

deletion

normal dosage

duplication

Nutrigenomics Definition
Analyzing the effects of diet on the activity of on
individuals genes and health and the effect of an
individuals genes on metabolism of dietary chemicals
Diet = nutritional science
Activity of genes = molecular biology
Individual = genetics/genomics
Health = physiology
A systems biology science : Multi - disciplinary
Nutrient is independent variable

Nutrient

Gene Expression

Gene expression is independent variable

What is Nutrigenomics?
Nutrigenomics

is the science that examines

the response of individuals to food compounds
using post-genomic and related technologies.
The long-term aim of nutrigenomics is to
understand how the whole body responds to
real foods using an integrated approach.
Studies using this approach can examine
people (i.e. populations, sub-populations based on genes or disease - and individuals),
food, life-stage and life-style without
preconceived ideas.
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17

Genes Lifestyle Calories

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18

Nutrigenomics
Target Genes
Mechanisms
Pathways

Foods
Nutrition

Molecular Nutrition
& Genomics

Signatures
Profiles
Biomarkers
Nutritional
Systems Biology

Identification of dietary signals

Identification of dietary sensors
Identification of target genes
Reconstruction of signaling pathways

Measurement of stress signatures

Identification of early biomarkers
Large research consortia
Big money

Small research groups

Small budgets
Complexity
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19

Molecular nutrition
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20

Nutrients acts as dietary

signals
Nutritional factors
Transcription factors
Gene transcription

Energy
homeostasis

Cell
proliferation

Nutrient
absorption

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21

Transcription-factor pathways
mediating nutrient-gene interaction

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22

Gene regulation
by nutrients

Gene expression
Prevention of
Signatures
Metabolic Syndrome

Dietary
Programming

Nutrient-related cellular sensing + Metabolic stress

Nutrients

Signaling

Target
Target
genes
genes
of
of nutrients
nutrients

Transporters
Transporters
Transcription
Transcription
factors
factors
Lipids
Lipids
Fatty
Fatty acids
acids
Sugars
Sugars
Calcium
Calcium

Enterocytes
Enterocytes
Hepatocytes
Hepatocytes
Adipocytes
Adipocytes
Lymphocytes
Lymphocytes
Signaling

Cells

Functions

Proteins

Genes

Cells

Metabolic
Metabolic
Implications
Implications
Metabolites
Metabolites

Proteins
Proteins
PostPosttranslational
translational
Regulation
Regulation
Genes

Organs

Proteins

Animal

Healthy Food

Mouse
Mouse
Models
Models

Intestine
Intestine
Liver,
Liver, Muscle
Muscle
Blood
Blood
Adipose
Adipose tissue
tissue
Functions

Humans

Organs

Animal

Intervention
Intervention
Studies
Studies

Humans

Diet-related organ sensing, Sensitivity genes + Molecular Phenotype

Molecular Biology
Tools

Transcriptome
Proteome
11/8/16

Metabolomics
Systems Biology

Early Molecular
Biomarkers
23

Two Strategies
(1) The traditional hypothesis-driven approach: specific genes and
proteins, the expression of which is influenced by nutrients, are
identified using genomics tools such as transcriptomics, proteomics
and metabolomics which subsequently allows the regulatory
pathways through which diet influences homeostasis to be identified .
Transgenic mouse models and cellular models are essential tools .
provide us with detailed molecular data on the interaction
between nutrition and the genome .
(2) The SYSTEMS BIOLOGY approach: gene, protein and metabolite
signatures that are associated with specific nutrients, or nutritional
regimes, are catalogued, and might provide early warningmolecular
biomarkers for nutrient-induced changes to homeostasis.
Be more important for human nutrition, given the difficulty of
collecting tissue samples from healthy individuals.
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24

Caloric restrictioninduced alterations in

gene expression

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25
Science (1999) 285:1390-139

Conclusion of gene expression profile of

aging and its retardation by caloric restriction

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26

Science (1999) 285:1390-13

Metabolic Syndrome and

Diabetes
Genes
Genes

Muscle
Muscle insulin
insulin
resistence
resistence
Obesity
Obesity

Increased
Increased
lipolysis
lipolysis in
in
visceral
visceral fat
fat

Ageing
Ageing

Increased
fatty acids levels

Increased
Increased
gluconeogenesis
gluconeogenesis
in
in liver
liver

Increased
glucose output

hyperinsulemia

Decreased
Decreased
glucose
glucose
tolerance
tolerance

Cell
Cell
compensation
compensation

Cell
Cell
decompensation
decompensation
11/8/16

Decreased
insulin
secretion

Diabetes
Diabetes

27

Signatures of health & stress -The two hits:

Metabolic and pro-inflammatory stress

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Strategies we need in gene-nutrient

interactions

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29

Nutrigenetics Definition
Effects of individual genetic variation in response
to nutrient
Any two individuals share 99% of their DNA sequence
Most common form of variation
Single nucleotide polymorphism (SNP)
Changes in single base pair
Occur ~ 1 in every 1000bp of human genome
(~ 3 million in human genome)

SNPs may alter regulation of gene expression,

mRNA processing (splicing, half-life etc) and protein
activities

Micronutrients that act directly or indirectly as

antioxidants or influence DNA expression
Vitamin
A

Vitamin
C

Vitamin
B12

Vitamin
B6

Vitamin
E

Vitamin
B3

Folic
acid

Vitamin
B2

Vitamin
D

Zn,Se,Fe
Mg, Cu

Antioxidants evolutions & Human

Health
Threat and management of
deleterious radicals generated
by cellular respiration

Membrane
Damage
Free
radicals
+
O2

Mitochhondria
l DNA
Damage
i ca
ad
e r gy
xid er
ro en
pe P
Su AT

Superoxide
dismutase

H2O2

Catalase

Nuclear DNA Damage

O2 + Glucose

H2O and
O2

Nutrigenomics (Nurture)
Nutrigenomics

Nutrition +
genomics
How do nutrients
alter gene
expression?

Transcription
Factor
DNA Target

Nucleus
Gene

Change mRNA
Essential
and nonessential
nutrients

Protein (< or >)

Biological
responses in
cell process(es)

Do nutrients affect gene

expression?
Vitamin E regulates protein kinase C activity in smooth
muscle cells (Azzi 1991)
Modulates the expression of the hepatic alpha-tocopherol
transfer protein (Hosomi 1997)
Tocopherol-dependent transcription factor (tocopherol
associated protein, TAP) has been identified (Stocker 1999)
CoQ10 in human muscle cells has shown effects on 12,000
genes (Linnane 2002)
Vitamin D3 affects 20,000 genes in human prostate cancer
cells (Krishnan 2003)
EGb 761 alters mRNA levels of the GLUT3 in hippocampal
neurons, increasing neuronal glucose supply in rats (Loffler
2001)
L-leucine interacts with multiple genes via mTOR and Akt
pathways

Iodine deficiency disorders

Kurang vitamin A

Defisiensi Folat

Nutritional assessment
Indirect

* dietary survey
* assessment of
ecological
factors

Direct

* biochemical test
* biophysical methods
* nutritional
anthropometry
* clinical sign

Dietary survey
National level

Household level

Individual level

Food

Food account

Single 24 hour recall

List recall

Multiple 24 hour recall

balance

sheet
Market data base

Food frequency
Food diary record
Weighed assessment

Gibson RS 1990. Principles of nutritional assessment

Human growth is influenced

by

1. Biological determinants :
sex, intra uterine environment,
birth order, birth weight, parental
size, genetic
constitution

2. Environmental :
Nutrition, Climate, living
condition,socio-economic condition,
diseases,
psychological factor etc

*Anthropometric Measurements =

picture of human growth at different age

level (from fetoes to adulthood):

height/length,

weight
upper arm circumference (UAC/LILA)
head circumference
BMI (body Mass Index)
Skinfold thickness

raw measurements do not mean

anything, if not compared to
REFERENCE or STANDARDS.

Body weight

Body length & height

Mid Upper Arm Circumference

Head circumference

Triceps Skin Fold

Knee height measurement

A

valid index of linear growth, can detect growth

increments in children more readily and over a short time
period in compared to height measurements.
Have a greater precision.
In infants: the growth is not linear, with a period of slow
and then accelerated growth
In adults: highly correlated with stature & maybe used to
estimate height in persons with severe spinal curvature
or who are unable to stand. The available formula are for
Caucasian and African-American. Population-specific
equations maybe necessary.
Body Weight can also be calculated from an equation
based on the values of calf circ, knee height, muac,
Subscap skinfold (for a selected population living in US)

Arm Span
Is

also highly correlated with stature.

Especially useful for assessing
retrospective measurement that is
stature prior to any age associated loss
in the elderly.
It is difficult to measure in non
ambulatory persons and individuals with
significant chest andspinal deformities.
A study showed that knee height is a
more valid estimate of maximum
stature during adulthood than arm span

Elbow breadth
Is

a good measure of skeletal dimensions/

frame size
Highly associated with lean body mass
and muscle size.

 Anthropometric

indices, not the raw

measurements, are interpreted and evaluated
For chidren: WHZ (for wasting) & HAZ (for
stunting) are the preferred anthropometric
indices of body size.
Anthropometric indices can be used at individual
and population levels for : assess nutritional
status, screening & response during intervention
At population level can be also used to identify
the determinants and consequences of
malnutrition and for nutritional surveillance.

Interpretation and evalution of

anthropometric data

KMS

WH
Z

HAZ WAZ

Usefullness in populations
where age is uncertain

Usefullness in identifying
wasted children

Sensitivity to weight change

over a sort period of time

Usefullness in identifying
stunted children

Selecting the appropriate indices

1:excellent, 4: poor

Klasifikasi status gizi

Indeks

Status

Keterangan

BB/U

Gizi lebih
Gizi baik
Gizi kurang
Gizi buruk

>= 2 SD
- 2 SD s/d +2 SD
-2 SD s/d 3 SD
< - 3 SD

TB/U

Normal
Pendek (stunted)

-2 SD s/d + 2 SD
< - 2SD

BB/TB

Gemuk
Normal
Kurus (wasted)
Sangat kurus

>= 2 SD
-2 SD s/d + 2 SD
< -2 SD s/d 3 SD
< - 3 SD

Interpretasi berdasar kombinasi indikator

Combination

Interpretation

BB/TB: N, BB/U: R, TB/U: R

Normally fed, with past history of malnutrition

BB/TB: N, BB/U: N, TB/U: N

Normal

BB/TB: N, BB/U: T, TB/U: T

Tall, normally nourished

BB/TB: R, BB/U:R, TB/U: T

Presently underfed ++

BB/TB: R, BB/U: R, TB/U: N

Presently underfed +

BB/TB: R, BB/U: N, TB/U: T

Presently underfed

BB/TB: T, BB/U: T, TB/U: R

Obese ++

BB/TB: T, BB/U: N, TB/U: R

Overfed with past history of malnutrition

BB/TB: T, BB/U: T, TB/U: N

Overfed but not necessarily obese

The advantages of anthropometric assessment

simple,

safe, inexpensive, non invasive

unskilled personnel can perform measurement procedures

precise and accurate
may be used to evaluate changes in nutritional status over time
and from one generation to the next
can assist in the identification of mild to moderate malnutrition,
as well as severe states of malnutrition

Limitations of anthropometric assessment

Relatively insensitive, cannot detect disturbance in
nutritional status over short periods of time or identify
specific nutrients deficiencies
Unable to distinguish disturbances in growth or body
composition induced by specific nutrient (e.g. Zinc)
deficiencies from those caused by imbalances in protein
and energy intake
Certain non-nutritional factors (disease, genetics, diurnal
variation) can reduce the specificity and sensitivity

Sources of error in nutritional anthropometry

Measurements

error : examiner, instrument, object

Alteration in the composition and physical properties of

certain tissues (tissue hydration, oedema, hepatomegaly)
Invalid assumptions : e.g. skin fold
in fact the relationship between subcutaneous and
internal fat is non linier

 Skinfold

thickness measurements:
Triceps skinfold
Biceps skinfold
Subscapular skinfold
Suprailiac skinfold
Midaxillary skinfold
Multiple skinfold measurements can be used for
measuring percent body fat

Anthropometric assessment of
body composition

 Waist

hip circumference ratio: >1.0 for men &

>0.85 for women indicated abdominal fat
accumulation & increase risk of cardiovascular
complications
Waist circumference: alone is the preferred
indicator of fat loss. For urban Asians: >80cm for
women & >90cm for men indicated central
obesity
Limb fat area: to estimate body fat
Percent body fat can be predicted by several
skinfld measurements

Anthropometric assessment of
body composition