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Fiona Pelly. A short summary of this paper. Download Download PDF. Translate PDF. Mosby Elsevier, St Louis, Missouri, , sports nutrition in any depth. Recognize the possibility of non-nutritional nationalistic misinterpretation of reference data Non nutritional, nationalistic and even political misinterpretations may sometimes occur, and these possibilities need to be borne in mind.
Thus, advocacy to use reference data largely derived from populations of European ancestry for other genetic groups may be rightly or wrongly interpreted as reflecting an unintended ethnocentric anthropometric imperialism 'West is best' or alternatively, as suggesting racial superiority. General types of reference data: With special reference to the assessment of protein-energy malnutrition in young children internationally available reference data, if different and if felt to be desirable and useful 'Internationally available reference data' should certainly be used when appropriate.
This approach is neat, orderly, and un inform. However, humanity is diverse genetically, culturally, and ecologically. Comparability is an understandable and worthwhile goal, but is insignificant compared with practical utility in stimulating worthwhile action.
Any fool can draw a line and many do. The issue is to produce a reasonable criterion for drawing such a line which will look like a sober decision and not a matter of caprice. Murphy Defining the Normal Nutritional assessment using any method, including anthropometry, presents no problem with extremes.
It is Normal Gaussian distribution curve. Conventionally, individuals less than the third percentile or centile approximately - 2 SD are regarded as probably abnormally low. In fact, by definition, three out of of a normal or reference population will fall into this group. In other words, some healthy, well-nourished adults will be smaller or taller than the average. However, the chance of their height being abnormal increases the ease to diagnose marasmus or gross obesity by visual anthropometry - that is, at a glance.
However, it is much more difficult and important to decide upon and agree to cut-off points or abnormal levels , below or above the reference data, which can be used to indicate less severe degrees of malnutrition. In the past such cut-off points have often been derived from percentages of the reference, 46 leading to qualitative categorization into different nominal levels, such as 'malnourished' or 'not malnourished', or into ordinal levels, such as 'severe', 'moderate', and 'mild'.
Nor the significance of selecting a particular point to be abnormal in terms of immediate or long-term consequences functional outcome , as regards subsequent morbidity or mortality. Further they are from the median. This seems likely to change slowly with increased emphasis on epidemiology and statistics in the curricula of medical and nursing students and other health workers. Severe underweight for height: 70 per cent -3SD. From a practical point of view, it can be very helpful to see if and how easily understood mathematical percentage levels compare with centiles or standard deviations.
For example, in young children the commonly used 80 per cent of weight-for-age equates approximately with the 3rd centile or - 2 SD. For example, the Gomez classification was initially devised because of the correlation of different 'degrees' of underweight with the mortality of hospitalized malnourished young children. Similarly, the original WHO low-birth- weight level of 2. Also, it must be emphasized that these figures were simple and easily remembered.
Unfortunately, functional outcome is not easy to measure - for practical reasons and because of the many and diverse influences which can affect individuals and communities. Also, the term 'functional outcome' can be viewed in various ways.
It can also apply to more long-term effects, such as neurological However, different measurements have different 'normal' distributions. Weight in health, well-fed individuals varies more than height. Also, some normal distributions, such as fat folds, are irregular non-Gaussian or skewed. This means that abnormal percentage levels for various measurements differ from their approximation with standard deviations, centiles, or 'Z-scores'.
Thus, - 2 WD for weight-for-age is roughly 80 per cent of the median, but for height is approximately 90 per cent of the median. Very approximate comparisons between statistical and mathematical levels for commonly used measurements are given in Table 2. Functional outcome In addition to knowledge of the distribution of an anthropometric measurement, it is important to try to recognize the meaning or significance of different levels in terms of function, and risk of illness and death, development, ultimate growth, etc.
A limited number of field investigations have been reported concerning the functional outcome in young children in less technically developed countries. For example, in Bangladesh Chen et al. Also, as noted earlier p. Other similar studies have been undertaken in adults.
It is merely a contusing statistical code term for the number of standard deviations below or above the reference median. It has been referred to in the present publication as it is widely used in scientific measurement. It could more simply be termed 'Standard Deviation score'. Modifications in selection of cut-off points may be required in different circumstances depending on practical needs e. Descriptive labels include, for example, 'severe' or 'desnutrido' or stage III Gomez classification.
Properties of 'normal' distributions, on the usually limited information on functional outcome, on clinical experience, on practical usefulness, and on understandability. None of these can give absolute truth; combined they can help to make an imperfect, but useful, selection possible. A guide to the thought processes which have often followed in the selection and labelling of cut- off points is given in the flow chart in Fig. In practice, cut-off points may need to be modified for particular situations - for example, screening in a refugee camp for different levels of rations compared with a cross-sectional prevalence survey.
Table 2. They need to be scientifically acceptable, of practical utility, and understandable to both measures and recipients of reports. Definitions of levels used and how they have been selected need to be fully included in any reports. Some characteristics are noted in Table 2.
However, the main purpose must never be lost sight of - to provide as rapidly, as economically, and as effectively as possible the most practical information for necessary action. However, for individuals this is especially difficult as each person has a unique 'life-flight' Trowell et al. In communities, data should aim at assisting in developing intersectoral national policy and local activities, including feasible, economical methods for use in primary health care services.
Negative result in a high proportion of those who are free of the disease or attribute under study , and predictive value resulting in high proportions of diseased, and disease-free, individuals among those with positive, and negative, test results respectively. The importance of a given property may vary widely, depending upon whether one id screening, case-finding, diagnosing, or conducting a survey.
The use and interpretation of anthropometry has been a matter of much debate in recent years. One concern has been uncertainty in the choice of anthropometric indices, and their interpretation. Anthropometric measurements do not distinguish between specific causes of malnutrition. This, however, makes them particularly useful as a general measure of nutritional outcome.
They indicate whether or not there is a problem, but not why there is a problem, nor what can be done about it. For this reason a number of other indicators are required. In summary, we can say that anthropometry is very useful because it provides: - Practical and objective problem description, - The best general proxy indicator for welfare of the poor and most vulnerable PEM and environmental health risks , - Description of over-and under-nutrition, - Strong and feasible predictor of ill-health and mortality in individuals and populations, - Under some circumstances, an appropriate indicator of the success or failure of interventions economic, health, environmental.
They usually involve the setting of a critical value, or cut-off point, e. The system is based on a comparison of observed weight of a child expressed as a percentage of the expected weight of a child of that age. Or, in other words- using weight-for-age as an indicator. Is relatively simple to understand and use in practice. Limitations: Does not take account of height differences. Age of the child must be known. Indicator: Weight-for-age. Waterlow recommends that children should be classified according to the degree of wasting and the degree of stunting.
He provides a two-way table and suggests how the cut-off points should be chosen. Limitations: The need for height, weight and age and the relative complexity of the classification could be a disadvantage in some situations. Such an anthropometric reference may be 'internal' with a national or regional population standard, but it may also be 'external', such as the WHO- adopted reference population.
Local and national standards are often poorly defined in statistical terms. Classification Schemes: Combinations of indices can give additional information concerning the quality or form of malnutrition present, as has been shown by Waterlow in a 2X2 diagram.
The categorization in stunted, wasted, and stunted and wasted is of practical significance. The stunted dwarfed child is usually the end-result of chronic, less severe, relatively 'balanced, inadequate nutrition'. These children show relatively normal body proportions, and on general inspection look younger than their actual age.
Such children are not such immediate public health priorities as wasted children and are not strongly associated with increased mortality in the near future. Recent evidence, however, suggests that the small but healthy classification of such children is not correct. The wasted child with more acute protein-energy malnutrition has a low weight-for-height, but relatively normal height. This type of child is need of early attention.
The body reserves of protein and calories are markedly depleted, so that there is a danger of the development of severe protein-energy malnutrition, either kwashiorkor or marasmus, especially if an infection occurs, which has an increased likelihood. The wasted and stunted child is suffering from acute malnutrition on a background of chronic malnutrition. Comment: While the Waterlow classification is to be recommended, there are three problems.
First, two measurements have to be made needing two apparatus. Second; increased chances of error, cost and complexity. Third, the child's age has to be known. Analysis: The measurements of reference population are usually presented in one or more of four ways: 1. Centiles Centiles indicate the percentage or proportion of measurements that fall at or below a certain value. Standard deviations Measurements are often expressed in terms of the number of standard deviations from the mean.
Percentage of 'standard', that is percentage of the standard population mean. Especially for populations where large numbers of children fall above or below the lower centiles. CSA, November Nutrition throughout the Life-cycle Life Introduction cycle. Introduction As the major communicable diseases, are gradually controlled, malnutrition is, and is likely to be for some time, the most important factor influencing the quality of human life in most developing countries.
Malnutrition is not only a major health problem, but also a serious impediment to national socioeconomic development. The underlying causes of malnutrition are varied.
They involve such variables as; - food production and related agricultural policies, - food distribution systems, - income possibilities for the rural and urban poor, - general education, - feeding habits and child-rearing practices, - availability and use of health services, - environmental sanitation, - an adequate supply of safe water, and many other related factors None of these can be neglected; they interact in highly significant ways.
The need for a coordinated multisectoral food and nutrition strategy stems from this fact. The health sector has an important role within this multisectoral framework. It provides services for general health care as well as specific interventions for nutrition promotion.
Even in the absence of specific nutrition intervention, general health measures can have an appreciable impact on nutritional status. Improved sanitation and provision of safe drinking-water can significantly reduce the incidence of gastrointestinal infections and parasitic infestations. Malaria control is another example of health sector intervention with considerable impact on nutritional status. Immunization programs can control the infectious diseases of childhood. The duration and severity of respiratory and gastrointestinal infections can be reduced.
Improved child-spacing can also be encouraged. In addition, mothers can be encouraged to adopt good child-feeding practices within the limits of their ability to follow them in the face of practical problems of hygiene, food preparation, feeding routines and the availability of recommended foods.
It is considered that even in the prevailing socioeconomic situation in most developing countries, if the nutrition interventions are properly conceived and implemented, they should have a definite impact on the nutrition and health status of a large segment of the population. More then any other sector, it is the health sector that receives directly the impact of malnutrition.
This situation is due in part to the direct effects of malnutrition, but also to the synergistic interaction of malnutrition and infection. It should however be recognized that the health services alone can not solve nutrition-related health problems when the causes are fundamentally rooted in the state of the society.
All the health-service-induced benefits mentioned earlier will not eliminate the basic causes of malnutrition among the populations who live below the poverty line.
In these circumstances, the problem is to try to make these people more productive. This needs a range of policies and programs within the framework of the national development plan; in other words, a comprehensive multisectoral food and nutrition strategy.
The limitations of a health sector's strategy, even through a successful primary health care approach, should be borne in mind. Types of responsibilities of the health sector It is widely recognized that malnutrition is a social disease having multiple causes lying in different developmental sectors. Being a multisectoral problem, malnutrition needs a comprehensive, coordinated food and nutrition strategy within the framework of a national socioeconomic development plan.
The health sector, or any other sector alone, would not be able to make any effective impact on the nutritional status of the population. However, the health sector is in a unique position, because of its capability and direct contact with the problem, to make important contributions to the prevention and control of malnutrition. In general terms, the responsibility of the health sector includes; - cooperation in the process of planning and implementation of the multi-sectoral strategy at the national level, - the provision of preventive ad curative services to the population at the community level, and - Participation in the monitoring and evaluation of nutrition plans and programs.
In order to have a sound basis for planning and implementing a multisectoral nutrition program in a country, the following conditions have to be fulfilled; 1. Complet knowledge is required of the nature, magnitude, geographical distribution and final effects of the prevalent nutrition problems in different population groups. This will aid the definition of both target groups and priority areas.
Knowledge of the main causative factors and environmental circumstances responsible for nutrition problems is required. It is important to underline that there are food-related and non-food-related determinant factors of malnutrition. This knowledge will allow the identification of specific strategies to control each of the nutrition problems, through both preventive and curative interventions.
An analysis of the existing resources and constraints is required in order to place the nutrition program on a realistic basis. The information on the magnitude, causes, and effects of nutrition problems should be stated clearly and made available to the public, and particularly to the policy-making groups and politicians, in order to promote the establishment of a sound food and nutrition policy and to motivate the allocation of sufficient funds for the implementation of nutrition plans and programs.
It should also be made available to sectoral planners, with special emphasis on their sector-related causes, effects and possible responsibilities for solving the problem. This will motivate the introduction of nutrition-oriented sectoral interventions and will facilitate the multisectoral coordination of programs. In addition to its contribution to the planning of national strategies, the health sector has direct responsibility for the prevention and control of malnutrition and other deficiency diseases.
Even when practical measures can not be found to reduce or eliminate the basic causes of malnutrition, the health sector can provide the means of improving the nutritional status of the population or alleviating the consequences of malnutrition. An understanding of the different variables producing malnutrition and ill-health will indicate the nature and type of the action to be taken.
Curative interventions are usually aimed at nutritional deficiencies in the clinical stage and are undertaken by the health services responsible for general medical care of the population.
Severe forms of protein-energy-malnutrition such as kwashiorkor and marasmus in infants and young children are by far the most important conditions calling for curative services. There is also a wide range of measures of primary prevention of malnutrition which fall under the health sector's responsibility.
These include; - educational activities for improving dietary practices, - food fortification, - supply of safe drinking-water, - family planning, - immunization, - Supplementary feeding programs for vulnerable groups. Another area of responsibility of the health sector relates to its participation in; - the assessment of the results of food and nutrition plans and programs, - the monitoring of changes, - the prediction of future trends for the nutrition problems in a country.
A nutrition surveillance system could be established for this purpose which should include both health and non-health indicators. The role of the health sector at different levels 2. Responsibilities at the national level - definition and analysis of nutritional problems, - promotion of multisectoral food and nutrition strategies and programs, - participation and cooperation in the establishment of the above strategies and programs, - participation and cooperation in the establishment and operation of a food and nutrition surveillance system.
The analysis should include the magnitude, distribution, causes and effects of nutritional deprivations on the individual, the community and the country as a whole, and their impact on the national economy and on other developmental sectors. The diagnosis of nutritional problems of the population is traditionally limited to the measurement of nutritional diseases or conditions e.
This approach, however, presents only a portion of the true impact of nutrition on health status. The contribution of nutrition to infectious disease, reproductive performance, mental development and other aspects of health status must also be recognized if the real magnitude of the problem is to be assessed and sufficient resources allocated for a permanent solution.
Promotion of multisectoral food and nutrition strategies and programs The main objective of the definition and analysis of existing food and nutrition problems in a country is to have a sound information base for adequate planning of effective strategies and coordinated multisectoral interventions to prevent and combat nutrition problems. With complete information in hand on the magnitude and effects of nutrition problems, the health sector should take the responsibility for disseminating this information widely, in particular to the politicians, including those at the highest levels of executive authority, in order to call attention to the need for a national nutrition policy and plan and to obtain final approval for such a plan.
It is thus important that workers and particularly planners in these other non-health sectors should be aware of the unfavorable impacts of malnutrition on the national economy, agreicultural productivity, educational performance and social stability, and should understand how nutritional deficiencies constitute a real obstacle to socioeconomic development.
It is clear therefore that to introduce nutrition components and orientation into these other sectors' programs and to facilitate multisectoral coordination, the health sector should take the responsibility for disseminating basic information on nutrition problems and their causes and effects, particularly to policy makers and sectoral planners. Participation and cooperation in the implementation of food and nutrition strategies and programs The health sector has the responsibility at the central level to identify and recommend specific strategies and relevant measures for correcting the problems that have been identified.
While only part of the possible measures for dealing with malnutrition falls within the sphere of action of the health sector, it is important that this sector should stimulate and cooperate with other sectors in relevant nutrition-related measures and also promote the consideration of nutrition- oriented objectives in the programs and projects on the other sectors.
In relation to certain specific nutritional deficiency diseases, the strategy and measures to be taken should be planned and carried out at the central level. Examples of such programs are iodination of common salt for control of endemic goiter and fortification of appropriate food vehicles with vitamin A or iron for controlling xerophthalmia and nutritional anemia.
Participation and cooperation in the establishment of a food and nutrition surveillance system The health sector should also play an important role in building a data support system for nutrition planning. In order to be most useful, such a system should be based on continuing data collection, i.
Responsibilities of the health sector at the community level Many cultural factors such as erroneous feeding habits, inappropriate practices and beliefs related to health and disease, inadequate child-rearing practices, and reproductive behavior are strong determination factors of malnutrition, which are usually very difficult to eliminate.
The health sector has a definite responsibility to carry out extended programs of nutrition education and health education in order to eliminate these causative factors. On the other hand, the synergistic action of malnutrition and infection stress the key role of the health sector not only in the diagnosis and treatment of malnutrition but also in the control of the determinant factors.
Diarrheal disease and infectious disease are common precipitating factors. Superimposed upon a background of under nutrition, these diseases are major setbacks in growth and development and can even lead to death. The responsibility of the health sector in the prevention of malnutrition is related to both the food factors, which are among the conditioning factors, and the non-food factors, which are among the precipitating factors leading to the appearance of severe forms of the disease.
Identification of malnutrition at the community level A good practice in this respect could be, for instance, to carry out a house-to-house survey of the weights by age of children under 5 years old, using a simple weighing scale. Even if the data obtained are not of the greatest accuracy, they will give the worker a general profile of the nutritional status of the young children in that community and will clearly identify the families at higher risk-namely, those with cases of second- or third-degree malnutrition.
The use of simple anthropometric measurements, such as weight, height, and arm circumference related to age or to each other weight-for-height, or arm-circumference for height , can give relatively accurate orientation of the current and past nutritional status of the children.
Similarly, the monitoring of weight gain during pregnancy can provide adequate information on maternal nutritional status and thus indirectly on fetal nutrition. The control of food factors at the community level Along with the traditional maternal and child health services as well as health education and family planning, food and nutrition activities should be an integral part of the "package" of health services delivered to the community at local level.
The mother should receive support and, if needed, appropriate advice on how to prepare herself for breast-feeding and also on the techniques of infant feeding at the weaning period and afterwards. A combination of monitoring maternal weight gain, advising on her diet and, when indicated, providing food or nutrient supplements particularly during the last trimester of pregnancy includes the ideal components for nutrition promotion for pregnant women at the community level.
In the field of nutrition education and health educaiton should be included, when required, the promotion of breast-feeding, guidance on infant and young child feeding such as the use of appropriate and timely complementary feeding and weaning , and advice on a balanced distribution of the available food within the family.
The distribution of iron tablets to all pregnant mothers and capsules of high-dosage vitamin A to children in order to prevent. Anemia and xerophthalmia, respectively, are other examples of the control at the local level of food factors responsible for malnutrition. The control of non-food factors at community level Very frequently the main determinant factor of the high prevalence of malnutrition in a given area or community group is not the lack of food at the family level or its inappropriate distribution within a family, but rather the in sanitary environment in the household, the lack of personal hygiene, the lack of periodic health care, and failure to vaccinate; all these are aggravated by short intervals in the case of large families living in crowded quarters, without adequate water supply, sewage facilities or refuse disposal.
An adequate food supply in such families cannot by itself correct the situation. A balanced food intake will be ineffective in the presence of inadequate utilization of nutrients which is due to repeated infectious disease and frequent diarrhoeal episodes. The traditional activities of primary and secondary prevention, particularly rough the MCH services at the community level, will control these non-food factors.
These activities include the monitoring of health, growth and development, early diagnosis and treatment of diseases, immunization programs, prevention and control of diarrhoeal diseases, oral rehydration, deworming, family planning activities, health education environmental sanitation programs, and the opportune referral of cases to higher levels of health care.
Those already malnourished need prompt nutrition rehabilitation. Most of this rehabilitation can be done at the community level and does not always require professional expertise. Nor are primary curative health care services to be overlooked, given their role in restoring health. Programs for the control of micronutrient deficiencies, especially IDD, are more amenable to immediate and effective action than those for the control of protein-energy malnutrition.
Success in preventing these deficiencies will provide useful experience and more confidence in tackling the general nutrition problems. Control of micronutrient deficiencies through supplementation can usefully be linked with existing immunization and antenatal care programs.
This is preferrable to setting up new vertical programs for micronutrients. A general improvement of famine prevention capacities. This will require early warning systems and strategic food reserves. Increased production of drought-resistant crops oriented to wards small-scale farming systems and the consumption of a wider variety of traditional foods in urban and rural areas. Vitamin C D. Fluoride Ans: C Which of the following is the best source for omega-3 fatty acids?
Corn oil B. Wheat products C. Pork D. Sardines Ans: D This mineral is essential for healthy red blood cells and a deficiency might cause anemia. Iron B.
Magnesium C. Iodine D. Chromium Ans: A This vitamin is needed to prevent a birth defect called Spina Bifida A.
Vitamin D B. Folate D. Vitamin E Ans: C This nutrient is needed for making hormones, healthier skin, and to make cell membranes: A.
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