Public Health Nutrition (Community Nutrition)

Public Health Nutrition(Community Nutrition)

Instructor: MC Huang

不均衡的飲食

Nutrition and Diseases

BiochemicalDamage

Chronic Diseases• Cancer• CVD• DM

Clinical Symptons營養不均衡

Overnutrition

Overnutritionundernutrition

Public Health (Community) Nutrition

Past problems:Past problems: undernutrition - goiter - goiter - beriberi, pellegra, scurvy - beriberi, pellegra, scurvy

Present problems: Present problems: overnutrition - malignant tumor - malignant tumor - cardiovascular diseases - cardiovascular diseases - diabetes mellitus - diabetes mellitus

國民營養調查國民營養調查Nutrition & Health Survey

in Taiwan

國民營養調查國民營養調查行政院衛生署食品衛生處為有效掌握國人營養以及健康狀況 ,1980 從年起進行全國性營養調查

國民營養調查第一次國民營養調查 (1980-81) 第二次國民營養調查 (1986-88) 1993-1996 第一次國民營養健康

狀況變遷調查調查 1997-2002 第二次國民營養健康

狀況變遷調查調查

台灣地區十大死亡原因惡性腫瘤事故傷害腦血管疾病心臟疾病糖尿病慢性肝病及肝硬化肺炎腎炎及腎症候群自殺支氣管炎 ,肺氣腫 ,氣喘

第一次國民營養調查 (1980-81)

調查方法：實際秤量食物盤存法 ( 台灣常用食品營養成分表）目的：調查家戶飲食狀況抽樣：分層隨機抽樣對象： 12 鄉鎮 539 戶 3163 人

第二次國民營養調查 (1986-88)

調查方法：實際秤量食物盤存法 ( 台灣常用食品營養成分表）目的：調查家戶飲食狀況抽樣：分層隨機抽樣對象： 12 鄉鎮 552 戶 20176 人

第三次國民營養調查第三次國民營養調查 (1993-9(1993-96)6)

第一次國民營養健康狀況變遷調查第一次國民營養健康狀況變遷調查調查方法：體位測量

生化檢驗 24 小時飲食回憶法食物頻率問卷營養 /健康 /行為問卷目的：飲食以及健康狀況變遷調查抽樣：分層隨機抽樣 /集體抽樣對象： 21 鄉鎮 63 村里 10080 人（四歲以

上）

取樣方式取樣方式第一次國民營養健康狀況變遷調查第一次國民營養健康狀況變遷調查

將台灣地區將台灣地區 365365 鄉鎮市區分成七層鄉鎮市區分成七層客家澎湖山地院轄市省轄市客家澎湖山地院轄市省轄市

都市化一級以及二級地區都市化一級以及二級地區以分層隨機抽樣的方式每層抽出以分層隨機抽樣的方式每層抽出

三個鄉鎮市區三個鄉鎮市區從鄉鎮市區再抽出三個村里從鄉鎮市區再抽出三個村里以集體抽樣的方式再抽出兩個首戶以集體抽樣的方式再抽出兩個首戶一個首戶對應兩個集區一個首戶對應兩個集區再以年齡層或性別層各抽出再以年齡層或性別層各抽出 8-168-16 個個個個

案案共共 10080 10080 抽樣人數（取樣：抽樣人數（取樣： 99629962 ））

體位測量體位測量第一次國民營養健康狀況變遷調查第一次國民營養健康狀況變遷調查

身高身高體重體重三頭肌以及肩胛後肌皮層厚度三頭肌以及肩胛後肌皮層厚度腰臀圍腰臀圍血壓血壓 ,, 心電圖心電圖生物抗阻生物抗阻

肥胖指標肥胖指標第一次國民營養健康狀況變遷調查第一次國民營養健康狀況變遷調查

理想理想體重 ≧體重 ≧ 120% 120% BMI ≧ 26.4BMI ≧ 26.4 三頭肌皮層厚度三頭肌皮層厚度

男≧ 男≧ 20mm 20mm 女≧女≧ 28m28mmm 體脂肪體脂肪

男≧ 男≧ 25% 25% 女≧女≧ 30% 30% 腰臀圍比腰臀圍比

男≧ 男≧ 0.9 0.9 女≧女≧ 0.850.85

飲食攝取狀況調查飲食攝取狀況調查第一次國民營養健康狀況變遷調查第一次國民營養健康狀況變遷調查

2424 小時飲食回憶小時飲食回憶 - - 每人每日營養素平均攝取量每人每日營養素平均攝取量 - - 和和 RDNARDNA 相較相較飲食頻率問卷飲食頻率問卷

- - 食物長期攝取情形食物長期攝取情形飲食營養及健康知識之行為問卷飲食營養及健康知識之行為問卷

- - 對營養飲食健康的認知以及行為表現對營養飲食健康的認知以及行為表現

飲食問卷飲食問卷 -- 量化分析量化分析

台灣地區食物營養成分資料台灣地區食物營養成分資料庫庫

SAS SAS 統計軟體統計軟體

健康狀況調查健康狀況調查第一次國民營養健康狀況變遷調查第一次國民營養健康狀況變遷調查

目的目的 - - 瞭解台灣地區瞭解台灣地區營養相關營養相關疾病盛行疾病盛行率率 - - 高血壓高血壓 ,, 糖尿病糖尿病 ,, 高血脂高血脂 ,, 高尿高尿酸酸

檢查項目檢查項目 - - 血中膽固醇血中膽固醇 ,, 三酸甘油酯三酸甘油酯 ,, 高低高低密度密度脂蛋白脂蛋白 ,, 尿酸尿酸 ,, 血糖血糖 - - 疾病問卷疾病問卷

第三次國民營養調查的意義第三次國民營養調查的意義

建立一個適合國人飲食型態以及長期營養健康偵測之方法

逐步將此一調查方法以及技術教導基層衛生單位 , 以落實基層保健工作

第四次國民營養調查第四次國民營養調查 (1997-2002)(1997-2002)第二次國民營養健康狀況變遷調查第二次國民營養健康狀況變遷調查

調查方法：基本資料健康狀況飲食狀況身體檢查目的：老人（兒童）飲食以及健康狀況變

遷抽樣：分層隨機抽樣 /集體抽樣對象： 39 鄉鎮 78 村里 2028 個老人

第四次國民營養調查第四次國民營養調查 (1997-2002)(1997-2002)第二次國民營養健康狀況變遷調查第二次國民營養健康狀況變遷調查

主負責單位 - 中央研究院生醫所

調查人員： - 衛生行政體系為架構 - 縣市衛生營養員負責調查方式

- 家戶調查 - 巡迴體檢

取樣方式取樣方式第二次國民營養健康狀況變遷調查第二次國民營養健康狀況變遷調查

將台灣地區以特殊族群或地理位置分層將台灣地區以特殊族群或地理位置分層客家澎湖山地東部北中南各三層客家澎湖山地東部北中南各三層以以分層隨機抽樣分層隨機抽樣的方式每層抽出的方式每層抽出

三個鄉鎮市區三個鄉鎮市區從鄉鎮市區再抽出二個村里從鄉鎮市區再抽出二個村里每一村里調查每一村里調查 2626 位老人位老人共共 20282028 人人

Community Nutrition in Actions

Nutrition assessment in community - ABCD

Nutritional program planning

Nutrition education Marketing nutrition for

health promotion and disease prevention

Nutritional program management

Epidemiological Findings

Nutritional Assessment

Nutritional Plan- define the problems- define goals & objective- develop a program plan- evaluate the program

Nutritional education

What knowledge doesa community nutritionist

need ??


Definition: The interpretation of information obtained from Anthropometric, Biochemical Clinical and Dietary studies.

The information used to determine - health status of individuals or population - influenced by their intake and utilization of nutrients.

Anthropometric Measurement

Definition: Measurements of the variations of the physical dimensions and gross composition of the human body at different age levels and degree of nutrition

Anthropometric Measurement Growth measurement

Head Circumference Weight - adult & children Height - adult & children

Ideal Body WeightAdult

M: 62 + [Ht (cm)-170) X 0.6 F: 58 + [Ht (cm)-158) X 0.5

M: [Ht (cm)-80] X 0.7 F: [Ht (cm)-70] X 0.6

22 X Ht (m2)

Indices for % of wt change (adult):

Usual Body Weight – Ideal Body Weight X 100%

Ideal Body Weight

Obese: + 20% Overweight: + 10-15% Normal: + 10% , normal Underweight: - 10-15% Marasmus: - 20 %

Indices for BMI - adult

Normal: 20-24.9 Obesity I: 25-29.9 Obesity II: 30-40 Obesity III: > 40

Indices for BMI – 6-18 歲

Usual BMI – 22 X 100% 22

身體質量指數百分位表 - 正常 : 25-75 percentile - 過重 : 75-95 percentile - 肥胖 : > 95% - 過輕 : 5-25 percentile - 消瘦 : < 5%

Indices of growth for children 0-6 歲身體發展曲線圖

Normal: 25-75 percentile Normal ?: 10-25/75-90 percentile Medical evaluation: <10 or >90 percentile Priority for medical evaluation/follow up

- <5 or > 95 percentile

Use of Growth Charts Public health office Community Health Nutrition surveys Physician’s office

站立 - > 3 yr old

平躺 (recumbent Length) - 0-6 yr old

評估依據 : 0-6, 6-15, 8-19 yr 身體發展曲線圖

Body Height - Direct Measurement

Body Height - Indirect Measurement

Arm Span

Knee Height

Male: 85.10 + 1.73X knee height – 0.11 X age

Female: 91.45 + 1.53X knee height – 0.16 X age

Body Composition Assessment

Body fat: content dependent on sex, height, weight

Fat free mass: mixture of water, protein, minerals

Body Fat : kg fat or % body wt

Triceps skinfold (TSF): mid point of the back of the upper left arm Biceps skinfold (BSF): thickness of a vertical fold on the front of the upper left arm Subscapular skinfold (SSF): below and laterally to the angle of the left shoulder blade Waist/Hip ratio (W/H) – M > 0.9; F>0.8 -> increased CVD risk -> 中間形肥胖

Skinfold Meaurement Measurement tool: capiler suitable for all ages’ measurement Indices: body fat or energy storage status assessment reference (評估依據 ):

Assessment reference Normal: 25-75 percentile Normal?: 10-25 percentile, 75-90 percentile Excessive body fat: > 90 percentile Body fat/protein exhaustion : <10 percentile

Fat free mass………

Mid-upper-arm Circumference (MAC) Mid-upper-arm Muscle Circumference (MAMC): “derived from MAC & TSF” MAMC = MAC-3.14X TSF

Arm Circumferance fat free mass assessment

Indices: body energy/protein storage status MAC, MAMC: usual indicator muscle area: preferable indicator than MAC/MAMC assessment reference (評估依據 ):

Assessment reference (MAC/MAMC) Normal: 60-90 percentile mild nutrition depletion: 25-60 percentile moderate nutrition depletion: 5-25 percentile severe nutrition depletion: <5 percentile

Fat mass: fat area measurement

Arm area (mm2): A = (3.14/4) X (MAC/3.14)2

Fat area (mm2): F = A – MAMA (mid-arm muscle area)

Skinfold Meaurement Measurement tool: capiler suitable for all ages’ measurement Indices: body fat or energy storage status assessment reference (評估依據 ):

Assessment reference Normal: 25-75 percentile Normal?: 10-25 percentile, 75-90 percentile Excessive body fat: > 90 percentile Body fat/protein exhaustion : <10 percentile

Correlations between Anthropometric variables & Body fat

% body fat Total body fat

Men women

Men Women

Weight 0.67 0.70 0.82 0.91

TSF 0.70 0.77 0.73 0.80

SSF 0.75 0.71 0.79 0.80

Am J Clin Nutr, Roche et al, 1981

Conclude anthropometric measConclude anthropometric measurement……urement……

Body fat content: combination of skinfold measurement

distribution of subcutaneous fat: Skinfold + W/H ratio

Fat free mass: “ MAC + TSF ” provide good indication for muscle area

No anthropometric indices are good indicators for short term nutritional support or deprivation

Biochemical MeasurementBiochemical Measurement

Laboratory assessment is used to detect subclinical deficiency state.

It provides objective means of assessing nutritional status, independent of emotional and other subjective factors.

Biochemical MeasurementBiochemical Measurement

measurement of a nutrient in biological fluid or tissues -> Blood: plasma/serum erythrocyte leukocyte/lymphocyte -> tissues: bone marrow, adipose tissues, bone hair, fingernails, toenails

Urinary excretion rate of a nutrient

Functional Tests: measuring abnormal metabolite or enzyme activities dependent upon a nutrient

Distribution of ProteinDistribution of Protein

Types g/kg Distribution

Muscle 22 Somatic protein

(exchangeable)

Skeleton 20 Somatic protein

(exchangeable)

Viscera 18 Visceral protein

(exchangeable)

Extracellular 17 Connective tissues,

Structural proteins

Fat 6

Somatic Protein StatusSomatic Protein Status

Urinary creatinine excretion/24 hr M: 20-26mg /kg/24hr

F: 14-22 mg/kg/24hr

Creatinine Height Index (CHI) CHI%= 24hr urinary creatinine X 100%

Ideal 24hr urinary creatinine for Ht

Normal condition: 90-100% moderate depletion: 60-90% severe depletion: >60%

Visceral protein statusVisceral protein status

Albumin: 3.5~5.0 g/dl Prealbumin: 15.7-29.6 mg/dl Globulin:

serum globulin 2.3~3.5 gm/dl A/G ratio- 1.2~1.9 mg/dl

Transferrin: 200~400 mg/dl RBP: 2.6~7.6 mg/dl Total serum pro: 6-8.4

Overall Protein StatusOverall Protein Status Short Method

nitrogen balance= (protein intake/6.25)-(urinary urea nitrogen+4)

Long Method

nitrogen balance= I- (U-Ue)+(F-Fe)+S

I: nitrogen intake in gram U: total urinary nitrogen Ue: endogenous urinary nitrogen F: Nitrogen excreted in feces Fe: endogenous fecal nitrogen loss

S: dermal nitrogen loss

CVD Risk based on Lipoprotein CVD Risk based on Lipoprotein Levels in DM AdultsLevels in DM Adults

Risk LDL Chol HDL Chol TG

High > 130 <35 > 400

Borderline 100-129 35-45 200-399

Low < 100 >45 <200

* Data is expressed as mg/dl

Vitamin AssessmentVitamin Assessment

Nutrient Examined Item

Vitamin A Serum Beta-carotene, Serum Retinol

Vitamin D 25-hydroxy-D3, alkaline phosphatase

Vitamin E Serum/plasma vitamin E

Vitamin K Clotting factors II, VII, IX, X, prothrombin Time

Vitamin Assessment…..Vitamin Assessment…..


Vitamin B1 Erythrocyte transketolase

Urine vitamin B1

Vitamin B2 Glutathione reductase,

Erythrocyte/urine vitamin B2

Niacin Urine methylnicotinamide

Vitamin B6 Tryptophan loading test

Pyridoxal phosphateerythrocyte transaminase (GOT/GPT)

Vitamin Assessment……Vitamin Assessment……


Folic acid Erythrocyte/serum folate

Homocysteine

Vitamin B12 Erythrocyte/serum vitamin B12

Urine methyl malonic acid

Vitamin C WBC/serum vitamin C

Mineral AssessmentMineral Assessment


Calcium Serum Ca, 24hr urinary Ca excretion

Phosphorus Serum phosphorus

Iodine Protein bound iodine, urinary iodine excretion, I125 absorption

Iron Serum Fe, total iron binding capacity

Transferrin saturation

Zinc Serum Zn, hair Zn

Organ Function TestsOrgan Function Tests

Organs Examined Item

Kidney BUN

Creatinine

Uric acid

Liver GOT

GPT

ALP

LDH

Ammonia

Pancrease Serum amylase

Serum Lipase

Clinical Clinical EvaluationEvaluation

Clinical assessment consists of a routine medical history and a physical examination to detect physical signs and symptons associated with malnutrition.

They are most useful during advanced stages of nutritional depletion.

Dietary Evaluation

24 Hour Dietary Recall Food Frequency Dietary History Food Diary Weighed Food Record

24 hr Dietary Recall

Methods: Recall the subject’s exact food intake during the previous 24 hr period

approach: face to face interview phone call interview

take home and record Pros: large-scale survey, high participation, cost less,

time efficient Cons: memory dependent, ignore seasoning, avoid

“bad food”, poor conception on serving size

Improving Validity of 24 hr Dietary Recall

Assist with food cards, food models Combined with food frequency and

dietary history Use repeated 24hr dietary record

Food Frequency Questionaire

Methods: use list of specific food items to record frequency of intakes over a given period. Only obtain qualitative, descriptive information

on food consumption pattern Approach: face to face interview

self-administered questionaire Pros: rapid

low respondent burden high response rate

Cons: low accuracy

Food Frequency Questionaire vs Epidemiology

Very often used in epidemiological studies Categorize subjects into low, mid, high

intakes for comparison with risk/protective effects on certain health issues

Dietary History

Methods: Interview method consist a 24 hr dietary recall,

questionaire on usual food intake pattern and followed by a food frequency questionaire. Such data is useful in food pattern associated with inadequate food intake.

Approach: face to face interview

Pros: understanding long-term food intake pattern high response rate

Cons: Labor intensive time consuming data validity is interviewers dependent

Weighed Food Record

Methods: All food consumed over a period is weighed. Useful in measuring actual intakes of individuals.

Approach: weighing food items at home

Pros: accurate time efficient

Cons: participants willingness decrease over time education dependent may affect subjects food intake habits


-Session end

維持理想體重維持理想體重維持理想體重

每日飲食指南- 推廣有利於國民健康的飲食習慣

五榖根莖類 : 3-6 碗奶類 : 1-2 杯蛋豆肉魚類 : 4 份蔬菜類 : 3 碟水果類 : 2 個


Food Guide Pyramid (USA)

Food Guide pyramid - to meet the nutritional needs for carbohydrate, protein, fat, vitamins & minerals

Not concerning the killer diseases in USA - DM, CVD, cancer, alcoholism

Killer diseases are associated with - over-consumption of calorie, fat, cholesterol salt - under-consumption of calcium, iron, folate - dietary fiber


Dietary Guidelines for Americans

Concerns - in response to diseases patterns in USA

Dietary Guidelines - eat a variety of food - balance the food you eat with exercise - choose a diet with plenty of grains, veg & fruit - choose a diet low in fat, SAT, cholesterol - choose a diet moderate in sugar - choose a diet moderate in salt & sodium - If you drink alcohol, do so in moderation

維持理想體重維持理想體重維持理想體重 Thank you for your attention


國民飲食原則 - 推廣有利於國民健康的飲食習慣

維持理想體重均衡攝食各類食物三餐以五榖為主食盡量選用高纖食物少鹽少油少糖的飲食原則攝取鈣質豐富的食物多喝白開水飲酒要節制

Documents

Public Health Nutrition (Community Nutrition)