Nutrition in Developing Countries

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Nutrition in Developing Countries
NUTR 555/HSERV 555
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Reasons communities support healthy diets

• Chronologic age
• Physiologic age / Functional Health
• Quality of life
• Healthy children

• Political Stability
• Environmental Quality
• Economic Growth / Productivity

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Concept Check
Consider What is your definition of
malnutrition?
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Learning Objectives

• Provide an orientation to the socio-ecological
  model
• Identify nutrition elements in the segments of
  the model
• Review segments of the model related to dietary/
  nutr assessment and needs
• Review the principles of nutrition for
• Energy CHO Protein Fats
• Micronutrients
• Discuss malnutrition and transition diets.

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Social Ecological Model
Health promotion approaches that are based on the
social-ecological model focus on the behavior
choices of each individual as well as situations
within each sphere that can influence health
behaviors. Gregson et al J Nutr Ed
200133(Suppl 1) S4-15.
Washington State Nutrition and Physical Activity
Plan, 2004
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Individual awareness, knowledge, attitudes,
beliefs, values, preferences Interpersonal
family, friends, peers that provide social
identify and support Institutional/organizational
rules, polices, procedures, environment,
informal structures Community Social networks,
norms standards and practices Public Policy
local, state, and federal government policies,
regulations and laws.
Washington State Nutrition and Physical Activity
Plan, 2004
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Policies/ Systems / Environment
Community
Institutional/ Organizational
Interpersonal
Individual
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Learning Objectives

• Provide an orientation to the socio-ecological
  model
• Identify nutrition elements in the segments of
  the model
• Review segments of the model related to dietary/
  nutr assessment and needs
• Review the principles of nutrition for
• Energy CHO Protein Fats
• Micronutrients
• Discuss malnutrition and transition diets.

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Progression of Elements of Basic Nutrition
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Recommended Intakes of Nutrients and Energy
Compared

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FAO Energy and Protein Requirements 2001
http//www.fao.org/docrep/003/AA040E/AA040E00.HTM
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Assessment of Individuals

• Body Weight / Anthropometrics
• Energy expenditure
• Essential Nutrients

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Energy Assessment
Basal metabolic rate 60 - 75
(Resting metabolic rate)
Physical Activity 15 - 30
Diet Induced 7 - 13
Other 2 - 7
Elia M. Energy expenditure in the whole body.
IN Energy Metabolism Tissue Determinants and
Cellular Corollaries, Eds. Kinney JM, Tucker HN,
Raven Press Ltd., New York, 1992.
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How do we measure energy?

• Food energy is measured in kilocalories (kcal).
• A kilocalorie is 1000 calories as used in
  scientific contexts.
• A kilocalorie is the amount of energy needed to
  heat 1000 cc (1 liter) of water one degree
  Celsius.
• When one hears the term Calorie in reference to
  food, it generally means a kilocalorie.

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Conversion Factors for Energy

• 1 joule (J) is the amount of mechanical energy
  required to displace a mass of 1 kg through a
  distance of 1 m with an acceleration of 1 m per
  second (1 J 1 kg 1 m2 1 sec-2).
• Multiples of 1 000 (kilojoules, kJ) or 1 million
  (megajoules, MJ) are used in human nutrition.
• The conversion factors between joules and
  calories are 1 kcal 4.184 kJ, or conversely, 1
  kJ 0.239 kcal.

FAO Energy and Protein Requirements 2001
http//www.fao.org/docrep/003/AA040E/AA040E00.HTM
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FAO Energy and Protein Requirements 2001
http//www.fao.org/docrep/003/AA040E/AA040E00.HTM
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FAO Energy and Protein Requirements 2001
http//www.fao.org/docrep/003/AA040E/AA040E00.HTM
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Methods of Assessment Energy
Figure 74-2 Schematic of body composition of a
healthy subject. Body cell mass (BCM) is shown by
shading as a composite of intracellular water,
glycogen, and protein. FFM, fat-free mass. From
Harrisons Online
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Evaluation of Body Weight
Body Mass Index Weight in kg / (Height in
Meters)2 Removes height from the formula
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Evaluation of Body Weight
Body Mass Index WHO Standards lt 16.0 PEM -
Level III 16.0 - 16.9 PEM - Level II 17.0 -
18.4 PEM - Level I 18.5 -
24.9 Desirable 25.0 - 29.9 Overweight gt
30.0 Obese gt 40.0 Severely Obese
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Evaluation of Body Weight
Limitations of these reference values Assumptions
behind the reference tables Age Gender Race
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Methods of Assessment Energy
What about Underweight?
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Body Composition

• Somatic Protein Stores
• Fat Free Mass
• Protein Stores - Lean body mass (LBM)
• Muscles
• Visceral Tissues
• Fluid Stores
• Fat Mass
• average for men 15
• average for women 28

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Body Composition
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The Five Elements of our Diets
Chemicals
Nutrients
Foods
Food Groups
Food Patterns
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Chemicals

• Hydrogen, Oxygen (Water)
• Carbon (Organic vs. Inorganic)
• Nitrogen (Protein)
• Cobalt - cobalamine - B12

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What are the six classes of nutrient?
Nutrients

• Carbohydrates
• Lipids
• Proteins
• Vitamins
• Minerals
• Water

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What are the three functional categories?

• Promote Growth and Development Proteins,
  lipids, vitamins, minerals, water
• Energy Carbohydrates, lipids, and protein.
• Regulate Body Processes Proteins, lipids,
  vitamins, minerals, water

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Which nutrients (and non-nutrients) provide
energy?

• The Macronutrients
• Carbohydrates (sugar, starch) 4 kcal/g
• Protein 4 kcal/g
• Lipids (fats, oils, cholesterol) 9 kcal/g
• Alcohol (not a nutrient) 7 kcal/g

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Nutrients

• Carbohydrates
• Lipids
• Proteins
• Vitamins
• Minerals
• Water

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Monosaccharides

• Structure
• Glucose
• Fructose
• Galactose

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Fructose

• Metabolized to glucose in the liver
• Metabolized to glycogen
• Metabolized to lactic acid
• Found in fruit, honey, and high fructose corn
  syrup

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Galactose

• Usually bound with glucose (lactose)
• Converted to glucose in the liver
• Available fuel source

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Complex carbohydrates

• Oligosaccharides raffinose stachyose
• Polysaccharides Starch Glycogen
• Dietary fiber

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Polysaccharides Starch

• 3,000 or more monosaccharides bound together
• Starch--alpha glycosidic bond
• Amylose--straight chain polymer
• Amylopectin--highly branched polymer
• Modified food starch and gel formation

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Dietary Fiber

• Undigested plant food
• Beta glycosidic bond
• Insoluble fiber
• Cellulose, hemicellulose, lignin
• Not fermented by the bacteria in the colon
• Soluble fiber
• Gum, Pectin, Mucilage
• Fruit, vegetable, rice bran, psyllium seed

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FAO Recommendations for CHO

• An optimum diet of at least 55 of total energy
  from a variety of carbohydrate sources for all
  ages except for children under the age of two.
• That the bulk of carbohydrate-containing foods
  consumed be those rich in non-starch
  polysaccharides and with a low glycemic index.
• Appropriately processed cereals, vegetables,
  legumes, and fruits are particularly good food
  choices.

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Nutrients

• Carbohydrates
• Lipids
• Proteins
• Vitamins
• Minerals
• Water

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Saturation Refers to the Degree to which Every
Possible Position on the Carbon Chain Is Occupied
by Hydrogen Atoms
Unsaturated points are where hydrogen atoms are
missing and replaced by double bonds between
carbon atoms.
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Dietary Fatty Acids Consist Of

• Short Chain fewer than 6 carbons
• Medium Chain 6 10 carbons
• Long Chain 12 24 carbons
• Saturated no double bonds
• Monounsaturated 1 double bond
• Polyunsaturated 2 or more double bonds

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Food Triglycerides Contain a Variety of Fatty
Acids

• Monounsaturated fatty acids are abundant in
  olive, peanut, and canola oils.
• Omega-6 polyunsaturated fatty acids are abundant
  in safflower, corn, and sunflower oils.
• Omega-3 polyunsaturated fatty acids are most
  abundant in fish and seafood, nuts, and some
  vegetable oils.
• Saturated fatty acids are high in meats and
  tropical palm and coconut oils.

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Unsaturated Fatty Acids Can Become

• Oxidized addition of oxygen molecules to
  carbons at double bonds rancidity
• Hydrogenated converted back to saturated form
  by addition of hydrogen at high temperature and
  pressure
• Trans-fatty acids by-product of hydrogenation
  where hydrogens are on opposite sides of double
  bonds

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Why are oils hydrogenated?

• Hydrogenation makes oils less prone to rancidity
  and makes them remain solid at higher
  temperatures.
• This is used primarily in the making of
  margarine, but partial hydrogenation also
  increases the shelf life of vegetable oils.

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FAO Recommendations for Fat Adults

• For most adults, dietary fat should supply at
  least 15 percent of their energy intake.
• Women of reproductive age should consume at least
  20 percent of their energy from fat.
• Concerted efforts should be made to ensure
  adequate consumption of dietary fat among
  populations where less than 15 percent of the
  dietary energy supply is from fat.
• Fat should not be specifically restricted below
  the age of 2 years. The optimum diet should be
  gradually introduced beginning at 2 years of age.
  

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Nutrients

• Carbohydrates
• Lipids
• Proteins
• Vitamins
• Minerals
• Water

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Proteins are the Most Complex of all Organic
Molecules

• Proteins consist of long chains (polypeptides) of
  variable subunits called amino acids
• There are 20 different kinds of amino acids found
  in proteins, each with a unique chemical
  structure
• The 20 different amino acids are used like an
  alphabet to spell out the structure of particular
  proteins

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Side Chains Provide Unique Chemical Properties to
Amino Acids

• Some side chains are attracted to water, while
  other lipid-like side chains are repelled by it
• Other side chains are repelled by or attracted to
  neighboring amino acids
• Some side chains form links with amino acids on
  other polypeptide chains
• These forces cause polypeptides to variously
  bend, twist, fold or coil

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Essential Amino Acids

• Some amino acids can be reassembled to make
  different amino acids these are called
  non-essential
• Other amino acids are essential in the diet
  they cannot be made by the human body
• There are nine essential amino acids in the human
  diet histidine, leucine, lysine, methionine,
  phenylalanine, threonine, tryptophan and valine

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Functions of Proteins in Our Bodies

• Structure Movement
• Enzymes Hormones
• Transport Antibodies
• Energy
• Fluid and Acid/Base Balance

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Nitrogen Balance

• Zero Balance Amount of Nitrogen Retained
  Amount of Nitrogen Excreted
• Positive Balance More Nitrogen Retained and
  Used to Make Proteins and Other Nitrogen
  Containing Compounds than Excreted (e.g. Growth)
• Negative Balance Nitrogen Not Utilized to Make
  Protein, More Excreted than Retained (e.g.
  Starvation)

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Steps Used in Setting Protein RDAs

• Extrapolate from Amounts Needed to Sustain Growth
  and/or from N Balance Studies
• Add 2 Standard Deviations (adequate to support
  needs of 97.5 of population)
• Add 10 for Digestibility
• Add 10 for Chemical Score (not in USA)
• Factor in Additional Needs for Pregnancy and
  Lactation

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What Happens When We Dont Eat Enough Protein?
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FAO Recommendations for Protein

• For adults the protein requirement per kg body
  weight is considered to be the same for both
  sexes at all ages and body weights within the
  acceptable range. The value accepted for the safe
  level of intake is 0.75 g per kg per day, in
  terms of proteins with the digestibility of milk
  or egg.

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c At 0.75 g per kg of protein with the quality
and digestibility of milk or egg.
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Nutrients

• Carbohydrates
• Lipids
• Proteins
• Vitamins
• Minerals
• Water

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Diet Assessment

• How do we assess diet?
• Methods
• Food Records
• FFQ
• 24 Hr Recalls with 5 Pass
• Strengths / Limitations

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Policies/ Systems / Environment
Community
Institutional/ Organizational
Interpersonal
Individual
Examples of Interpersonal influences on food /
nutrition _________
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Concept Check
Describe cultural and social influences that
impact food availability.
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Household Distribution of Food

• The household is the basic unit for food
  consumption under most settings, and if there is
  sufficient food, individual members of the
  household can consume a diet with the recommended
  nutrient densities and meet their specific RNIs.
• However, appropriate food distribution within the
  family must be considered to ensure that children
  and women receive adequate food with high
  micronutrient density.
• Household food distribution must be considered
  when establishing general dietary guidelines and
  addressing the needs of vulnerable groups in the
  community.
• In addition, education detailing the appropriate
  storage and processing of foods to prevent
  micronutrient losses at the household level is
  important.

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Concept Check
Consider Are there good and bad foods?
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Policies/ Systems / Environment
Community
Institutional/ Organizational
Interpersonal
Individual
Examples of Institutional/ Organizational
influences on food / nutrition _______________
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Causes of Hunger

• Status of Women and Education
• Illiterate girls
• may marry as early as 11 years of age
• may have seven children before 18 years of age
• Girls who go to school
• marry later
• have an average of 50 fewer children
• spacing of births
• each additional year of school results in a 5-10
  decrease in mortality among her children

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Policies/ Systems / Environment
Community
Institutional/ Organizational
Interpersonal
Individual
Examples of Community influences on food /
nutrition _________
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Food Groups

• Breads, Cereals and other Grains
• Vegetables
• Fruits
• Meat, Poultry, Fish Alternates
• Milk, Cheese and Yogurt
• Fats, Sweets, Alcoholic Beverages

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FAO CHO in Human Nutrition
Figure 3 - Energy from the dominant starch
staples, 1990-1992
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FAO CHO in Human Nutrition
Figure 2 - Starchy staples providing the highest
proportion of food energy, 1990-1992
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Policies/ Systems / Environment
Community
Institutional/ Organizational
Interpersonal
Individual
Examples of Policies/ Systems/ Environment that
influences food / nutrition __
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Other Policies

• Existing
• Breastfeeding
• Supplementation
• Potential other policies

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Learning Objectives

• Provide an orientation to the socio-ecological
  model
• Identify nutrition elements in the segments of
  the model
• Review segments of the model related to dietary/
  nutr assessment and needs
• Review the principles of nutrition for
• Energy CHO Protein Fats
• Micronutrients
• Discuss malnutrition and transition diets.

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What is nutrition transition?

• The shift in dietary pattern that occurs as
  incomes increase
• Diet shifts from one high in complex
  carbohydrates and fiber to a more varied diet
  higher in fats, saturated fat, and sugar

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Nutrition Transition
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The Two Faces of Malnutrition

• Overnutrition
• A diet high in energy, saturated fat,
  cholesterol, and sodium, but low in fiber
• Cardiovascular disease
• Obesity
• Cancer
• Diabetes
• Osteoporosis
• Undernutrition
• A diet low in either energy or various specific
  nutrients
• Low birth weight
• Higher infant mortality rate
• Stunting
• Infectious disease

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FAO The nutrition transition and obesity

• The underweight and overweight share
• high levels of sickness and disability,
• shortened life spans and
• reduced productivity.
• Obesity increases the risk of chronic diseases
  such as diabetes, hypertension, heart disease,
  stroke, gall bladder disease and a number of
  cancers.

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Obesity and income

• In China, when per capita income grew fourfold
  after the economic reforms of the late 1970s, the
  consumption of high-fat foods soared.
• While incomes grew, the income needed to purchase
  a fatty diet decreased. In 1962, a diet
  containing 20 percent of total energy from fat
  correlated with a per capita GNP of US1 475. By
  1990, a GNP of just 750 correlated with the same
  diet.

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http//www.fao.org/focus/e/obesity/obes1.htm
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Prevalence of Obesity in some Countries
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Obesity related Diabetes

• The developing world risks suffering the lion's
  share of the growing disease burden.
• The number of people is expected to double to
• 300 million between 1998 and 2025
• 75 (225 million)- projected in the developing
  world.
• For nations whose economic and social resources
  are already stretched to the limit, the result
  could be disastrous.

FAO The nutrition transition and obesity
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Concept Check
What will health planners need to address the
threat of obesity?
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Future Directions

• Unfortunately, data from developing countries are
  limited. As a result, policy makers don't have
  what they need to evaluate the threat of
  increasing obesity and the rise of related
  chronic diseases. And the misconception that
  obesity is a problem afflicting only affluent
  countries may be holding back further research

FAO The nutrition transition and obesity