Community Nutrition

Dept. of Public Health and Preventive MedicineFMUP

Epidemiology

Developing countries >> Low socioeconomic status Reproductive women Deficiency Fe main cause of anemia Genetic Deficiency folic acid

IRON DEFICIENCY ANEMIA (IDA)

Fe Deficiency abnormal biochemistry of Fe with or without anemia, caused by;

-decrease bioavailibility of Fe intake. -increase need of Fe(pregnant,lactation ) -increase blood loss (ankylostoma)

Anemia by Fe deficiency occur in severe anemia make the body can not maintain body temperature and could be fatal.

IRON DEFICIENCY ANEMIA (IDA)

Severe anemia (Hb< 4 g/dl) post delivery stress O2 function decreased death.

In pregnant woman low birth weight, prematurity.

Influence also O2 transportation work capacity and productivity decrease

In baby and children influence behavior and intelligence

Factors influence anemia 1. Lack of Fe intake In average woman need 6,5 ug/ day. Inhibitor fitat and polifenol ( in

cereal,peanut, coffee, tea, vegetable)

Enhancer ascorbic acid, and animal protein (cow & chicken meat, fish)

2. Increase physiological need Increase during pregnant, for increasing blood volume, for fetus and placenta, and blood loss during delivery.

Factors.....................cont 3. Excessive blood loss Blood loss can be occurred during operation, disease, menstruation. In average a woman lost 27 cc of blood per menstruation cycle. About 10% lost

more than 80 cc. IUD increase lost of blood 2X, Pill can

decrease amount of menstruation blood 1,5X.

FACTORS..................cont

Placenta praevia and placenta abruption become the risk of lost of blood after delivery process

In average during delivery a woman lost 500 cc blood

Exclusive breast feeding prolong amenorrhae of mother.

Infection /parasitic infection like hook-worm corelate positively with anemia

Blooding can also occurred caused by drug consumption like adrenocorticosteroid, aspirin

Factors.................contLaboratory Increase Hb > 1 g/dl after 1 month Fe

suplementation Fe deficiency anemia Serum feritin < 12mg/cc Fe deficiency Fe status analysis can use concentration of

ferritin serum, saturation transferin, erithrocyt protophorfirin, transferin receptor concentration.

Serum feritin is specific indicator for Fe deficiency during low Fe level.

During infection and edema serum feritin also increase.

Prevention and therapy of IDA

PREVENTION : maintain equilibrium between Fe intake with the need and lost of Fe.

To increase Fe input increase food consumption contain heme-iron.

If not enough from diet Fe supplement Fe supplementation need discipline of the patient. Side effect of Fe is gastric disturbance

Fortification of cereal product is one of strategy for increasing Fe consumption in community.

Prevention............cont

SCREENING Screening is very important to identify

woman group to be treated for reducing anemia morbidity.

CDC Atlanta suggest that woman (youth and adult not pregnant) should be screened every 5-10 years.

If there is risk for developing anemia, screening is conducted yearly.

For pregnant woman screening should be conducted during PNC.

Prevention................cont

THERAPY: Anemia patient should consume 60-120

mg Fe per day and increase consumption of Fe through diet. Check after 1 month, Hb should increase minimal 1g/dl.

Pregnant woman with mild anemia should treated with Fe 60-120mg /day .

After Hb and Haematocrit normal 30 mg/day.

IODINE DEFICIENCY

Deficiency can develop since prenatal stage until old age .

Before, known as Enlargement of Thyroid (Gondok Ind) Can cause abortion, still birth, cretin,

hypothyroid.

ECOLOGY AND DEMOGRAPHY

Not all country have Iodine mineral resources. Most of natural iodine are in the sea and in

the soil. Iodine in soil as I and at the sea as I2

In sea water 50-60ug/l, air 0,7 ug/l, rain water 1,8-8,5 ug/l

Ecology...................cont

Yodium easy to evaporate and sensitive to the light. Yodium from sea water evaporate to

the air to soil with rain or snow. If soil can not keep water to river then to

the sea. In area which cannot keep water

endemic area of deficiency yodium

The cycle

ETIOLOGY OF YODIUM DEFICIENCY

In general nutrition problems can be divided into two :

-Primary: No equilibrium b/w the need and the input. -Secondary: Body cannot use nutrient eg caused by inborn defect metabolism.

UNICEF conceptDisturbance by Yod Deficiency

Lack input of Yodium

Food low Yod Salt w/o Yodium

Lack of education about diseaseAnd the advantage of salt w/ Yodium

Resource & control•Health man power

•Economy & organization

Politics, ideology, structure & economic

Potential resources(Yodium in soil low )

Toxicity and hyperthyroid

According to Wolf (WHO 1996) excess of iodine can be

divided into 4 groups. Moderate excess of iodine increase absorption

of iodine in thyroid gland and increase production of organic iodine.

Big enough excess of iodine will inhibit release of iodine from thyroxin in and from thyroid gland where release of iodine increased by TSH .

Big excess of iodine inhibit production of organic iodine Goiter

Very big excess will saturate active transportation mechanism of iodine ion

Intake more than 2000 ug Iodine / day dangerous .

Big intake from sea do not dangerous, like in Japan/ china

- thyroid function is normal although more or less than

30 mg/day

- incidence of non-toxic diffuse goiter and toxic goiter

will decreased.

- incidence of Graves and Hashimoto do not influence

by high intake of iodine.

- high intake of iodine will induce hypothyroid and

inhibit effect of thioamide drug.

CRETIN Cretin is caused by irreversible iodine

deficiency. Most dangerous deficiency of iodine. IQ in cretin below standard. Become a burden for a long time (until dead) In general Cretin is developed, if during

organogenesis there is iodine deficiency. Cretin can be seen clearly after the age of baby

more than 12 months Prevalence in baby with breast feeding is less

than baby with formula milk.

Diagnosis Diagnosed based on damage of central nervous

system Symptoms : mental retardation, bilateral

perceptive deaf, neuro-motoric damage. Hypothyroid obstacle of height and weight

development In severe hypothyroid myxoedema In mild hypothyroid ossification inhibition

Early sign & symptoms Weak and sleepy (lethargic) Growth problems Constipation Swollen face and dumb expression Chink-eyes Thick and big tongue Rough and dry hair. Fat deposit at fossa supraclavicularis and neck. Big belly and hernia umbilical Short and fat, dry skin and low body temperature Non pitting edema.

Iodine status examination Biochemistry : - creatinin in urine ; normal = more than 50ug I2/g creatinin hypothyroid = 25-50 ug I2/g creatinin cretin = < 25 ug I2/ g creatinin Thyroid gland enlargement 2 stages stage II can be seen in normal head position stage I cannot be seen in normal head position but visible when the head in lift up position.

Indicator for thyroid gland enlargement

Total Goiter rate (TGR) and Visible Goiter Rate (VGR)

TGR= Group I + Group II / children examine x 100

VGR= Group II / children examine x 100 Mild TGR 5,0 – 19,0% Medium TGR 20,0 – 29,0% Severe- TGR > 30%

Program

In mild area salt iodization and economic development,

In medium area salt iodization 20-40 ppm and iodine oil capsules

In severe area iodine oil capsules

Program steps Situation analyses of disorder cause by

deficiency of Iodine. Communicate data to health and public

health professionals . Plan of action by MOH. Socialization of program in local language Organization development and partnership with local government. Monitoring & evaluation.

4. Vitamin A deficiency

Diagnosed by :

Parameter / classification of xerophthalmia

Vitamin A value and plasma carotene

Food consumption review / anamnestic (contribute)

Xerophthalmia classification :

X 1 A Conjunctival xerosis

X 1 B Bitot’s spot + X 1 A

X 2 Corneal xerosis

X 3 A Corneal Ulceration + xerosis

X 3 B Keratomalacia

X S Corneal Scar

X N Night Blindness

X B Bitot’s spot

VAD criteria as national public health problem if (Indonesia Health Department) :

1. X 1 B more than 2,0 %

2. X 2 + X 3 A + X 3 B more than 0,01 %

3. X S more than 0,1 %

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