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A mixture of food stuffs selected to satisfy the nutritional requirements of the body in quality and quantity. It should be safe and of good taste and smell. It should be suitable for weather age, effort and physiological status of every one.
Dr. Dalia El-Shafei
Assoc. prof., Community Medicine Department, Zagazig University
Identify sources, functions, effect of deficiency of nutrients.
Understand the characteristics of adequate, balanced diet.
Develop a diet plan by using the dietary guides and nutritional pyramid.
Describe diets for vulnerable groups.
Understand the causes, manifestations and control of malnutrition problems.
Explain methods of assessment of nutritional status.
Describe diet plans for selected chronic diseases (therapeutic diet).
FACTORS AFFECTING ENERGY REQUIREMENTS
• Type & duration of activity and
size of the person.
Lean body mass (LBM)
• ↑LBM →↑Metabolic activity
• ↑BMR & energy requirements
during periods of growth then ↓ at
• ↑Energy requirements in low
atmospheric temperature to
maintain body temperature.
• ↑BMR by 7% for each ↑0.83°C in
Pregnancy & lactation
• ↑BMR & energy requirements.
ESTIMATION OF ENERGY REQUIREMENTS
• 1.0 K.cal/kg BW
/h (for men)
• 0.9 K.cal/ kg BW
/h (for women)
• BMR/day = 1.0 or
0.9 x BW x 24
• Sedentary life =
20% of BMR
• Very light activity
= 30% of BMR
• Moderate activity
= 40% of BMR
• Heavy activity =
50% of BMR
action of food
• Energy needed for
food) = 10% of
Energy requirements = BMR + Phys. Activity + S.D.F.
A serving of a high-fiber food, such as backed beans
results in lower blood glucose levels compared to the
size serving of mashed potatoes which results in a
higher blood glucose level.
Why are we concerned with the effects of various foods
on blood glucose? Foods that result in a high blood
glucose level elicit a large release of insulin from the
pancreas which chronically will lead to many bad
effects on the body.
Two food measurements have been developed which are
useful in predicting the blood sugar response to various
foods and in diet planning to avoid hyperglycemia.
GLYCEMIC INDEX (GI)
It is a measure of how quickly foods that contain
carbohydrate raise blood glucose levels.
Some foods cause a rapid rise in blood glucose (with a high
GI) while others cause a gradual rise (with a low GI).
This depends on starch structure, fiber content, food
processing and other food contents as fat.
GLYCEMIC LOAD (GL)
• Another way of describing how different foods affect
blood glucose levels
• More useful because it considers the glycemic index &
the amount of carbohydrate consumed.
Glycemic load = Glycemic index X Grams of CHO serving /100
A mixture of food stuffs selected to satisfy the nutritional
requirements of the body in quality and quantity.
It should be safe and of good taste and smell.
It should be suitable for weather age, effort and
physiological status of everyone.
Every day, food must contain all nutritional elements (all levels
of the guide pyramid).
Eat nutritionally adequate food “Variety of foods; 20% of total
calories from proteins, 25% from fats & the rest from
Drink plenty of water.
Don't eat between meals (snacking only by fruits & vegetables).
Eat 5-6 small meals instead of 3 huge meals & last-meal must
be before 9 PM.
↓ Salt & refined sugars intake (white poisons).
↓ Intake of canned, preserved, smoked and salted foods.
Check for expired dates for canned & frozen foods and do not
eat nuts stored for long periods (contain aflatoxin).
↑ Consumption of fresh fruits & green leafy vegetables.
↓ Intake of ready-made foods (fast foods) and too much
processed foods “full of saturated fats & cholesterol”.
↑ Consumption of dietary fibers & complex
carbohydrate (whole grain bread).
↑ Consumption of calcium containing foods
(green leafy vegetable, fish with bones and milk).
↓ Consumption of total fats especially saturated
fats and cholesterol containing foods.
Use vegetable oils instead of margarine (trans-
fats) for cooking
In (2011) the Nutritional Guide Pyramid was replaced with a new
and simpler icon, My Plate. It is based on how our food, drink, and
activity choices affect our health.
Make most of your meal
vegetables & fruits – ½ of
• Aim for color and variety
• Potatoes don’t count as vegetables
because of their negative impact on
Go for whole grains – ¼ of
• Whole and intact grains—whole
wheat, barley, oats, brown rice, and
foods made with them,
• Milder effect on blood sugar &
insulin than refined grains.
Protein power – ¼ of your
• Fish, chicken, beans, and nuts.
• Limit red meat and avoid processed
meats such as hamburger and
Healthy plant oils – in
• Healthy vegetable oils like olive,
canola, soy, corn, sunflower, peanut
• Avoid partially hydrogenated oils
“contain unhealthy trans fats”.
• Low-fat does Not mean “healthy.”
Drink water, coffee, or tea:
• Skip sugary drinks
• Limit milk & dairy products to 1-2
servings per day
• Limit juice to a small glass per day.
• The red figure running across the
Healthy Eating Plate’s placemat is a
reminder that staying active is also
important in weight control.
ARE THE RELATIVE SIZES OF THE HEALTHY EATING PLATE
SECTIONS BASED ON CALORIES OR VOLUME?
The Healthy Eating Plate does not define a certain number of calories or servings
per day from each food group.
The relative section sizes suggest approximate relative proportions of each of
the food groups to include on a healthy plate.
They are not based on specific calorie amounts, and they are not meant to
prescribe a certain number of calories or servings per day, since individuals’
calorie and nutrient needs vary based on age, gender, body size, and level of
Nutrition plays a major role throughout each stage of the life cycle.
There are nutritionally vulnerable groups who are at risk due to
increased physiological needs to certain nutrients.
FEEDING OF INFANTS “BREAST FEEDING”
Advantages of breast milk
• Secreted in the first 3-4 days in small amount.
• High contents of carotene, maternal antibodies, digestible proteins, less sugar and fat and
more sodium, potassium and chloride.
• Rich in proteins, vitamins, mineral, IgA and galactolipid (for brain growth).
• Contains hormones, growth factors & anti-bacterial factors as lysozymes, macrophages.
• Contains lactoferrin which binds iron for absorption and prevents bacterial multiplication.
• It is bacteriologically safe, ready made, sterile always fresh and of suitable temperature.
• Its amount regulated by baby suckling according to his need.
• It reduces risk of infections, allergy and obesity of infants.
Mature breast milk
Advantages of breast-feeding process
Has good psychological
effect on baby & mother and
initiating early mother baby
Promotes development of
jaws, teeth and speech
pattern of baby.
Helps uterine involution.
↓ Risk of post partum
↓ Risk of cancer breast &
Easier for mother and saves
her money that paid in bottle
Requirements of breast feeding
• Start as early as possible to stimulate milk
1st 6 months • Exclusive "No other food”.
After 6th month
• Weaning started by introduction of other foods
with breast milk
• To face the rapid growth & development of baby
and compensate some deficient nutrients in milk
• Start is with fluids, semisolid and solid foods.
• Use spoon or cup not bottle before breast
• If diarrhea occurs, stop this food and replace by
FEEDING OF PREGNANT & LACTATING MOTHERS
They need more nutritional elements because of:
Growth of the
↑ BMR. Production of
FEEDING OF PRESCHOOL & SCHOOL CHILDREN
rapid growth &
↑ Need of food rich
in proteins, calcium,
iron, vit.D, vita.C,
vit.B complex and
FEEDING OF ADOLESCENTS
period body mass ↑
by 35% in boys &
20% in girls.
FEEDING OF THE ELDERLY
↓ Requirements of all nutrients
due to ↓ BMR, & ↓ activities.
Methods of Nutritional Assessment
Investigation of the nutritional status
Dietary survey Health appraisal
Weight & height
Serum or urine
Availability Prices Production Importation
Dietary survey Health appraisal
Investigation of the
NATIONAL FOOD CONSUMPTION
For estimation of the average food consumption (the
national diet) the food-balance sheet technique is used.
Food balance sheet technique
• Determining the individual share from different foods assuming
that the available foods are distributed equally among the
• It is used for the community as a whole
• The different foods are divided into “11” similar groups as
cereals, starchy roots, pulses and legumes, sugar and honey, fresh
vegetables, fruits, meat and poultry …etc.
• Calculation of local production of these food groups plus the
amount of foods imported or donated.
• From the above calculation a subtraction of the amount of food
exported plus that not used by human beings (not-edible) is done.
• The difference is called the “Balance” which is the amount
consumed by the population. It is then divided by No. of
population and by 360 to get the individual share in grams from
the national foods per day.
The consumption of different
food items as milk, meat, eggs
….etc are analyzed into their
nutrients and energy to give the
individual consumption of
each nutrient (as protein, fats,
vitamins, iron …etc) and
energy per day.
• Explores the national food
consumption & the main defects
• Used to compare between average
food consumption in successive
years to show the trend of
• Used to compare between different
• By using it, we can identify the
main sources of different
nutrients in the national diet as
protein & iron contents in Egyptian
diet are mainly from plant sources.
• Assumes that the food is
distributed equally throughout the
year among the population which is
not true due to different socio-
economic conditions and seasons.
• Ignores differences in
requirements of people regarding
age, sex, occupation, physical
Cereals (especially bread) & legumes form the main bulk of diet.
“Supply the greater part of energy, proteins, iron, vit. B & fibres”
Energy is in excess than required (high carbohydrates & fats).
The protein content is mainly from the plant sources (low
Moderate consumption of vegetables & fruits.
Low consumption of meat, milk & eggs.
Iron intake is high but mainly from plant sources (cereals) which
is of low absorbability.
Impact on nutritional status of Egyptians
Iron & B12
• Carried out to find out if the food intake satisfies the individuals’
• Can be done on individuals or homogenous groups (families, camps,
patients in a hospital) provided that these groups of population eat from
a common kitchen. It is more precise and feasible.
• All foods used in preparing meals are weighing every day with
subtracting the unused parts and wastes. The actual amount of food
which eaten/day are calculated for a special period (one week) then
the end amount divided/No. of individuals in the group/No. of days
(7) to get the actual individual share in food consumption/day.
• Concerned with what
people are eating which
considered a private
• Its occurrence by itself
change the pattern of
• More accurate &
feasible (represents the
food actually eaten).
• Suitable for nutritional
experimentation e.g., to
test variations in diet or
the effect of introduction
of new foods.
HEALTH APPRAISAL (COMPREHENSIVE CLINICAL
• Comprehensive nutritional interview
to detect living conditions, habits, culture
and economic & psychological factors ...
• Malnutrition, parasitic & chronic
• Simple & cheap method “Recall of all
foods consumed the previous day to the
test but it is not suitable for old
(COMPREHENSIVE CLINICAL EXAMINATION)
It is done to detect physical signs of nutritional deficiency.
However, this will be somewhat late as against every case
showing frank clinical manifestations at least there are
“10” cases in the subclinical (biochemical or functional)
Defect in body functions and frank manifestations of malnutrition
Detected by clinical examination and anthropometric measurements.
↓Enzymatic activity and physiological functions
Detected by biochemical and physiological testing
↓Plasma levels of some nutrients
Detected by biochemical testing
↓Food intake or ↑loss
Detected by dietary history, survey.
Effect of nutritional deficiency passes into stages:
Skin, hair & nails
• To detect manifestations of vit. A,
B1, B3 & protein deficiencies
Head & neck
• To detect signs of iron, Ca,
iodine, vit.B2, C & fluorine
Muscles & skeletal system
• To detect P.E.M. & rickets
• To detect signs of vit. B1, B3,
B12 & Ca deficiencies.
• To detect vit. B1 deficiency.
Clinical signs & symptoms are not often specific.
Body can adapt to very low intake especially with
sufficient body stores.
Clinical signs take long period to be manifested
“young women having deficient intake of Ca & vita.D
often suffers no ill effects in young age, but they face ↑
risk of osteoporosis after many years”.
Limitations of clinical examination method:
Weight & height
They are used mainly
to evaluate nutritional
status of children.
Each of them is
plotted on growth
charts against age for
Height for age
• <5th percentile of the
→ Stunted child
(short for age) in
Weight for height
• <5th percentile of
Wasted child (thin
for age) in acute
Weight for age
• <5th percentile of the
for age in both acute
& chronic under-
WHO indices for growth monitoring of children:
Body Mass Index (BMI)(Quetelet's index):
Good measure of overweight not obesity as weight may increase due to
excess muscularity or oedema not always due to excess fat deposition.
Skin fold thickness (S.F.T.)
Skin thickness over mid-
triceps or mid biceps
muscles or subscapular
or suprailiac regions are
measured by certain
caliber in millimeters.
It is used in infants &
children to assess obesity
Mid-upper arm circumference (MUAC)
Measuring the circumference of mid-non dominant upper arm by
using non-stretchable tape.
Readings are measured in centimeters and compared with standard
It provides a good measure of the subcutaneous fat reserve as S.F.T.
Should not exceed 88cm for females & 102 cm for males.
Waist hip ratio (WHR): Should be <1, if above denotes android obesity.
investigations Blood Hg Detection of iron
Serum or urine
Assess the level of the different nutrients
“amino acids, serum retinol, iodine,
some vitamins & alkaline phosphatase
enzyme level to diagnose vit. D
Stool analysis Intestinal parasites
Dark adaptation test &
muscle activity test
THESE METHODS OF ASSESSMENT CAN BE USED:
On the community level
• National food consumption
• Dietary survey.
• Relevant data & vital indices.
On the individual's level
• Dietary survey.
• Clinical health appraisal.
• Anthropometric measurements.
• Laboratory investigations.