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community medicine

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  1. 1. Dr. Dalia El-ShafeiDr. Dalia El-Shafei Lecturer, Community MedicineLecturer, Community Medicine Department, Zagazig UniversityDepartment, Zagazig University
  2. 2.  Microcytic, hypochromic anemia.  Decreased HG concentration than standards.  The most prevalent single deficiency state on a worldwide basis.  Important economically “diminishes the capability of individuals to perform physical labor, growth and learning capacity in children”
  3. 3. 1. Decreased intake of animal proteins 2. Bad dietary habits (intake of tea after meals) 3. Parasitic infections 4. Inadequate dietary intake especially when requirements are high “pregnancy, rapid growth”. 5. Impaired iron absorption “low vit C intake, gastric Hypoacidity, iron Precipitation by oxalates & phosphates”. 6. Chronic blood loss.
  4. 4. 1. Pale skin, loss of appetite & apathy. 2. Fatigue. 3. Decreased attention, learning ability, work performance & immune status. 4. Dry brittle nails which later become flat & spoon shaped.
  5. 5. 1- C/P. 2- Haemic murmurs. 3- Blood picture:  Low HG>11gm./dL.(different cut-off(s) in different ages)  Decreased RBCs.  Small color index 0.5-0.7.
  6. 6. 1.Adequate dietary intake. 2.Dietary supplementation “dry milk and bread” 3.Prevention & control of parasitic diseases & pathological conditions associated with blood loss. Early detection by lab testing.Early detection by lab testing.
  7. 7. (B12-Folate deficiency Anemia)
  8. 8. Deficiency of vitamin B12 & Folic acid arrests the development of erythrocytes in the bone marrow at the stage of megaloblasts.
  9. 9. o Pregnant & lactating women due to increased demand. o Vegetarians whose diet lacks vitamin B12. o Gastrectomy “lacking of intrinsic factor needed for absorption of B12”. o Diphyllobothrium latum infestation as it consumes B12. o Malabsorption syndrome. o Medications that treat diabetes, acid reflux, and peptic ulcers.
  10. 10. GIT, NS, and CVS. Chest pain or heart palpitations, Confusion, memory loss, Depression or dementia, Constipation, Pale skin or jaundice, poor appetite, sore mouth and tongue and weight loss. Developmental delays and failure to thrive. Fatigue or weakness, Numbness or coldness of hands and feet.
  11. 11.  Balanced diet with considerable intake of animal food.  Supplementation of pregnant and lactating women and vegetarians with B12 and folic acid.  Atrophic gastric mucosa or who had gastrectomy should be given intrinsic factor.
  12. 12. Regulates the nerve cells of the embryonic development. C/p: If deficiency during pregnancy Neural tube defect, spina bifida & anencephaly. Low birth weight, Preterm delivery, Anemia Prevention: encourage consumption of Liver, Kidney, Fish, Green leafy vegetables, and Beans. Folic acid supplementation if needed.
  13. 13. Osteomalacia Osteoporosis Def. Bone Softening "bone replaced by soft osteoid tissue". Bone Atrophy "significant reduction of bone density & mass more than 2.5 SD " Path. Vit. D or Ca++ & Ph---deficiency  failure to replace bone turnover  demineralized soft osteoid tissue. Bone mass starts to decline after age 40 ys. due to resorption > formation ---too little bone but with normal mineral content. RF  Young women with repeated pregnancy.  Indoor living conditions.  Diet deficient in Ca++, Ph---  Malabsorption & chronic renal failure.  Post menopasual women & Elderly.  Insufficient intake “Ca++, Ph---, vit.D”  Smoking, alcoholism  Sedentary life  Delayed pubeity, hypogonadism  Endocrinal diseases as cushing's syndrome.  Drugs “corticosteroids, cytotoxic drugs.  Malignancy (lymphoma), CRF  Low body weight.
  14. 14. Osteomalacia Osteoporosis C/P  Bone-ache, tenderness  Uneven gait due to muscular weakness  May be a symptomatic  Persistant backache due to progressive compression and collapse of vertebrae  Kyphosis, hip fracture. TTT Ca++ & vit. D supplementation.  Early cases: Ca++, vit. D supplementation.  Late cases: antiresorptive drugs.
  15. 15. Most important cause of blindness in developingMost important cause of blindness in developing countries.countries.
  16. 16.  Delayed growth, decrease in iron utilization, follicular keratosis of the skin & increased susceptibility to respiratory & urinary tract infections (anti-infection vit.).  Night blindness: nyctalopia or day sight.  Conjunctival xerosis due to affection of the lacrimal gland  Bitot spots in the cornea  Xerophthalmia, Corneal ulceration and keratomalacia  Blindness
  17. 17.  Nutrition education  M.C.H. Services: mothers after labor (200 000IU) infants as drops at 9th month (100 000IU) & another dose at 18th month (200 000IU)  Fortification of foods with vitamin A as margarines, vegetable oils and dried skimmed milk.
  18. 18. Thiamine (vitamin B1) deficiency
  19. 19.  Common in South East Asia where many diets consist solely of white rice.  Affects nervous & circulatory system  C/P: muscle wasting & nerve damage.  Prevention: foods such as pork, beef and whole grain (unrefined) breads and grains.
  20. 20. Niacin or vit B3 (or Tryptophan) deficiency
  21. 21.  Consumption of corn “poorly absorbed”.  C/P: "3 Ds"; diarrhea, dementia and dermatitis.  Prevention: broccoli, eggs, dates, beef, salmon, seeds and peanuts.
  22. 22. Vitamin C deficiency
  23. 23.  In bottle fed infants, pregnant, elderly, workers in desert who consumed canned food.  C/P: general weakness, muscle & joint pain, swelling of gums, bleeding, blepharitis, anemia, Stomatitis, gingivitis & impaired healing of wounds. Hge under skin & joints provoked by slight trauma. Anemia occurs because of decreased iron absorption.
  24. 24.  Increase intake of fresh vegetables and fruits. (vit C is heat labile, easily oxidized and destroyed by storage).  Nutrition education.  Supplying infant during weaning by orange & tomato juice  Dietary supplementation by food rich in vit C for the high-risk groups in camps or isolated communities.
  25. 25.  Most important cause of preventable brain damage and mental retardation in babies.  Lower IQ by 10-15%.  Deficiency gives hypothyroidosis and goitre.  Stillbirth and miscarriage.  Cretinism: mental retardation, stunted, hypothyroidis, deaf-mutism.  Prevention: Iodising salt, Sea fish, sea plants (vegetables grown on iodized soil).
  26. 26. Def in Ca, ph, vitamin D, and fluorine. Ingestion of carbohydrates, sugars, & soft drinks with neglecting oral hygiene.
  27. 27.  C/P: growth retardation & increased susceptibility to infections especially skin & eye lesions.  Prevention: consumption of foods as: Whole-grain cereals, Legumes, Meat, & Chicken and fish.
  28. 28. Obesity
  29. 29. Definition: it is excess adipose tissue in different parts in the body due to excess storage of fat. The ability to store fat is unlimited but if the amount of fat to be stored exceeds the ability of the fat cells to expand (50 times its size), the body forms new adipose cells. With weight loss, fat cells decrease in size but not in number. Once a fat cell formed, it exists for life.
  30. 30. Imbalance between energy intake & energy expenditure for long periods of time.
  31. 31. Risk factors
  32. 32. A. Biological factors (non-modifiable): 1. Genetics: Brown adipose tissue: interscapular adipose tissue and along the aorta. Thin persons have more brown adipose tissue, so that fat oxidized more than stored.
  33. 33. Leptin ”satiety factor: It is a hormone secreted from adipocytes with central control from hypothalamus. suppress appetite, deplete fat stores and increase energy expenditure. In obesity there is a state of leptin resistance at cell level with hyperleptinaemia leading to some complications as cardiovascular disorders.
  34. 34. Ghrelin: hormone produced in the stomach. Its secretion stimulated by adrenaline and nor-adrenaline which are released in response to hypoglycemia where it promotes the appetite.
  35. 35. 2. Age: Obesity may appear at any age but obesity in childhood is predictive to obesity later on adulthood. 3. Sex: Both sexes are exposed. Pregnancy causes increase in mother weight by 4-6 pounds over her pre-pregnancy weight. Menopause represents a risk period for extra weight gain and redistribution of fat towards visceral regions.
  36. 36. B. Behavioural factors (modifiable factors): 1. Diet : eat more than need in quality & quantity :  Taking much sweets, fats and snacks.  Nibbling in between meals.  Consuming soft drinks regularly.  Evening overeating. 2. Physical inactivity : sedentary occupations, preferring indoor life and with least activity. 3. Psychological & emotional disorders: anxiety, psychological stress & depressive illness “emotional relieve”.
  37. 37. C. Environmental factors (modifiable factors): Family lifestyle and feeding pattern, work problems and unemployment and effect of advanced technology and foods advertisements on feeding pattern.
  38. 38. fat distribution in the body which is of morbid significance: Pear-shaped obesity (gynacoid type): in females, where fat located in hips and thighs. Apple-shaped obesity (android type): in males, where fat located around waist and abdomen.
  39. 39. 1. BMI is not a sensitive index (BMI > 30)
  40. 40. 2. Skin fold thickness.
  41. 41. 3. Relative weight : (RW=body weight "kg"/desirable body weight "kg" x 100)  RW is supposed to be 100%.  Desirable body weight for each height is obtained from special tables.  RW > 120% is considered obesity.
  42. 42. 4. Waist/hip ratio: if > 85%: android obesity “more health hazards as cardiovascular problems”. If <85% : gynacoid obesity.
  43. 43. 5. Arm Fat Area (AFA): it is a measure of total body fat (fat weight) and calculated from mid-arm circumference and triceps skin fold thickness by certain equation as : AFA = arm area - arm muscle area.
  44. 44. 6. Hydrostatic water weighing (densitometry): It is comparing of body weight on standard scale with the weight underwater. By assuming that adipose tissue is less dense than lean tissue (muscles and bones), so the more adipose tissue in a body, the less its underwater weight (the more it tends to float). It is an accurate method for estimating the total body fat.
  45. 45. Management of obesity:
  46. 46. I) Life style modification: 1. Diet: decreasing caloric intake by about 500 Kcal./day to achieve a weight loss of 450 gm/week. Because of the way the body uses fuel from carbohydrates, fats and protein, a more rapid weight loss will compel the body to use protein (muscles) instead of fat for energy. This will decrease muscle mass with each dieting attempt and fat percentage will increase. Other principles of healthy eating relevant to weight loss:  Eat plenty of food rich in starch and fibres.  Eat plenty of fruits and vegetables.  Avoid eating too much fat and sugars.  Not skip meals “suppress metabolism”.
  47. 47. 2. Physical activity: Generally walking or swimming are safe exercise for all persons. Those who are bed ridden or are in wheel-chairs can use upper arm exercises. Aerobic exercises require more air and tend to use the highest percentage of body fat for fuel. 1. Decrease body fat while helping to preserve muscles tissue tone. 2. Manage mental stress. 3. Increase energy levels. 4. Control of appetite. 5. Improve blood sugar control in diabetes. 6. Reduce blood pressure. 7. ↑amounts of HDL-C. 8. Improve bone density where weight-bearing exercises can slow down bone loss after menopause or even increase bone density.
  48. 48. 3. Behavioural modification: By focusing on small, gradual behavioural changes, the individual learns to gain control on eating behaviours with the goal of permanent changes in eating habits. Some basic strategies can be useful in promoting behaviour changes for sustained weight loss include: Self-monitoring - behavioural contracting – stimulus control (which precedes eating) - cognitive restructuring - stress management - social support physical activity and relapse prevention.
  49. 49. II) Medications: Some drugs are used to control obesity as those used for appetite suppression or prevention of fat absorption. Other drugs used for supplementation of vitamins and minerals or for management of obesity complications.
  50. 50. III) Surgery: It is used in cases of morbid obesity (BMI > 40) or in cases of failure of other methods to control of obesity.
  51. 51. Complications of obesity:
  52. 52. 1. Cardiovascular: main cause of death in obese. A) Coronary heart disease: Hyperinsulinaemia (insulin resistance). Hypertriglyceridemia (dyslipidemia). B) Hypertension: which lead to more renal sodium retention and catecholamines release.
  53. 53. 2. Diabetes mellitus: Insulin resistance syndrome: due to defect in the insulin receptors at the cell level leading to inability of the body cells to utilize blood sugar to give the needed energy. 3. Other complications: As: musculoskeletal disorders, gout, some types of cancer (colon, breast), gall stones, hernias and menstrual irregularities.
  54. 54.  To prevent or manage some medical conditions  To maintain or improve health through the use of appropriate and healthy food choices  To achieve and maintain optimal metabolic and physiological outcome.
  55. 55. DASH eating plan: -It is a dietary approach to stop hypertension (DASH). -It is a flexible and balanced eating plan which recommends: 1. More servings of vegetables and fruits (3-4 servings/d). 2. Whole grain cereals and bread. 3. Fat-free or low fat dairy products (3 servings/d). 4. Lower saturated fats, cholesterol and total fats. 5. Limiting lean meat intake. 6. Fewer sweets and added sugars. 7. Low sodium (salt) intake (> 2.3 mg /day.). 8. More foods rich in potassium as: milk, banana, orange, and legumes. 9. Two or more vegetarian-style or meatless meals each week.
  56. 56. Making heart healthy lifestyle changes while following the DASH eating plan is the best way to control hypertension through the following: 1. Maintaining a healthy weight (in overweight or obesity; reducing daily caloric intake by 500-1000 kcal. to have a weight loss of 1-2 pounds /week. 2. Be physically active. 3. Making healthy eating choices that less in sodium (by using of spices, lemon, vinegar or other salt-free seasoning blends). 4. Stop smoking: as smoking harms every organ in the body.
  57. 57.  Reduced intake of cholesterol, trans-fats, saturated fats & salt.  Saturated fats: <7% of total calories  Dietary cholesterol: <200 mg per day  Total fat: 25–30% of total calories  Increase intake of unsaturated fats as: olive oil and omega- 3oil in fish  Carbohydrate: 50–60% of total calories  Fibers: 20–30 grams per day  Protein: Approximately 15-20% of total calories  Total calories (energy): Balanced energy intake and expenditure.
  58. 58. *Choose more high fiber foods: (more fruits and vegetables)  To help maintain blood glucose levels and cholesterol levels: As: *Fruits, *Vegetables* Pulses* Oats  To help maintain a healthy gut: Whole grain cereals,* Whole grain bread,* Whole wheat pasta,* Brown rice, *Reduce animal or saturated fat intake  Use low fat milk  Use low fat spread instead of butter  Use oil high in unsaturated fat, e.g: olive oil, omega-3 oils in fish  Use less fat in cooking : grill, dry-roast, steam
  59. 59. *Cut down on sugary foods  Cut out sweets, eat starchy foods.  Cut out sugary drinks .Use diet or low calorie, sugar free drinks  Choose low sugar products *Reduce salt intake  Cut down on added salt  Use alternative seasonings  Look out for reduced/low sodium foods, e.g: bread  Avoid salt substitutes  Eat regular meals
  60. 60. Extremely complicated. Intended to reduce the amount of excretory work demanded of the kidneys while helping them maintains fluid, acid-base, and electrolyte balance.  Patients with CRF may have restricted proteins, Na, K, Ph.  Sufficient calories necessary: 25 to 50 kcal per kilogram of body weight.  Diet may limit protein to 40 grams based on glomerular filtration rate and weight. Protein increases the amount of nitrogen waste the kidneys must handle.  Sodium may be limited if the client tends to retain it.  Fluids are typically restricted for renal patients.  Calcium supplements may be prescribed.  Vitamin D may be added and phosphorus limited, to prevent osteomalcia.  Potassium may be restricted in some patients because hyperkalemia tends to occur in end stage renal disease (ESRD).Excess potassium can cause cardiac arrest.  Renal patients often have an increased need for vitamins B, C, and D.  Iron is commonly prescribed.
  61. 61. Diet therapy in liver cirrhosis:  Provides at least 25 to 35 kcal or more.  In advanced cirrhosis, 50 to 60% of the kcal. should be taken from carbohydrates.  Provides 0.8 to 1.0g of protein per kilogram of weight each day.  Supplements of vitamins and minerals are usually needed.  Sometimes cirrhosis causes ascites: Sodium and fluids may be restricted.  If there is bleeding in the esophagus, fibers can be restricted to prevent irritation of the tissue.  Smaller feedings will be better accepted than larger ones.  Alcohol is prohibited
  62. 62. Diet therapy in Hepatitis:  Diet should provide 35 to 40 kcal/ kgm. body weight: provided by carbohydrates with restriction of fat  If necrosis is not severe, up to 70 to 80 grams of protein for cell regeneration.  If necrosis is severe and the proteins cannot be properly metabolized, they must be limited to prevent the accumulation of ammonia in the blood.
  63. 63. Diet therapy in Peptic Ulcers:  Sufficient low-fat protein should be provided.  No less than 0.8g of protein per kilogram of body weight recommended.  Avoid caffeine, beverages, alcohol, aspirin, and smoking.  Well-balanced diet of three meals a day.
  64. 64. A) Nutritional excess: 1. Increased caloric intake  obesity  cancer breast, uterus, oesophagus …etc. 2. Increased saturated fatty acids  tumour growth. 3. Excess salting  cancer stomach and oesophagus. B) Carcinogens in foods: 1. Microbial toxins: aflatoxins in long stored nuts  cancer liver. 2. Chemical toxins: pesticides, herbicides, nitrogenous fertilizers. 3. Packing materials: soldered canned food, lead pipes  cancer kidney, alum in water purification and cadmium in food industry. 4. Chloroform in water and alcohol. 5. Polycyclic aromatic hydrocarbons from food grilling over direct flame. 6. Food additives: colors, flavors, sweeteners, preservatives.
  65. 65. 1. Fibres have a protective effect against cancer colon. 2. Fruits and vegetables: rich in antioxidants (vit. A, E, C). 3. Lenolenic fatty acid (polyunsat. FA) has protective role against cancer breast and colon. 4. Selenium is an antioxidant and calcium has anticancer role. 5. Coffee and tea have useful role in prevention of cancer colon.
  66. 66. Infection can lead to malnutrition by causing anorexia, vomiting, diarrhea or bleeding. Increased supply for nutrients to compensate for the losses is needed. Malnutrition interferes with body formation of antibodies (immunoglobulins) lymphocytes and phagocytes. Vitamins A, C and B2 are responsible for normal proliferation of phagocytes and lining epithelium of the respiratory and urinary tracts. These nutrients deficiency increases body susceptibility to infection.
  67. 67. In the body the oxidation reactions involve highly reactive molecules called free radicals. When these free radicals are released from the mitochondria in sufficient numbers they threaten the protective biochemical systems of the body and the cell structures and functions(damage cell proteins, lipoproteins and DNA)and can lead to diseases, as cancer, coronary heart diseases, arthritis, diabetes and neurodegenerative diseases as Alzheimer.
  68. 68. Oxidative stress: impaired balance between free radical production and antioxidant capacity resulting in excess oxidative products. Sources of free radicals: Extrinsic: as radiation, pollution, smoking, pesticides and toxins Intrinsic: as stress and inflammation. Antioxidants are chemical compounds which may be endogenous as superoxid dismutase enzyme in the human cells or exogenous as vitamins E, C, A, selenium, zinc and phytochemicals in foods. These antioxidants neutralize the free radicals preventing them from damaging healthy cells.
  69. 69. Sources of antioxidants (exogenous): 1. Beta-carotene: in apricots, carrots, mangoes. 2. Copper: seafood, milk, nuts and lean meat. 3. Selenium: onion, garlic, wheat germ, mushrooms. 4. Vitamin C: broccoli, cabbage, strawberry. 5. Vitamin E: whole grain cereals, nuts, wheat germ, mangoes. 6. Phytochemicals: green tea, apple, citrus fruits, onion, tomatoes, garlic.
  70. 70. Functions of antioxidants: 1. Against senility, cancer and cardiovascular diseases. 2. Prevent progress of rheumatoid arthritis, diabetes and parkinsonism. 3. Decrease muscle damage in athletes. 4. Prevent rancidity in food preservatives and cosmetics industries. 5. Help to reduce menopausal symptoms and osteoporosis.
  71. 71. It is a practice of diet that excludes meat, fish and poultry, egg, milk and honey i.e., excludes any food from animal source.  Lacto-vegetarianism: consuming milk and excluding the other animal foods.  Ovo-vegetarianism: consuming eggs and excluding the other animal foods.  Semi-vegetarianism: excluding meat only.
  72. 72. Causes of choosing vegetarian diet: 1. Mortality. 2. Religion. 3. Culture. 4. Ethical. 5. Environmental. 6. Economical. 7. Political. 8. Taste. 9. Morbidity. Benefits: it is considered a healthy diet if well planned as it can reduce risk of cancer, ischaemic heart diseases, hypertension and obesity. Hazards: the only deficient nutrient is vit. B12 as it is found only in animal protein.
  73. 73. Thank you