Levels of Prevention

DR.RUKHSAR ALI SHAHANI

DEPARTMENT OF COMMUNITY
MEDICINE ISRA UNIVERSITY
HYDERABAD
 Objectives
• To know the different levels of prevention
• To understand its role in public health
 Objectives
• To know the basic nutrients and their
functions in our body
• To identify the different problems due to
lack of these nutrients
• To know how to use basic tools in
identifying undernourished children
• To be aware of the common malnutrition
problems in the Philippines and the
government’s intervention to address
these issues
 Levels of Prevention
• Primary Level of Prevention
• Secondary Level of Prevention
• Tertiary Level of Prevention
 Primary Level of Prevention
• control the underlying cause or condition
that may result in disability
• e.g. maternal antiretroviral therapy to
reduce the risk of mother-to-child
transmission of HIV; fortification of the
food supply to prevent birth defects such
as spina bifida and iodine deficiency
disorders
Goiter
 Secondary Level of Prevention
• aims at preventing an existing illness or
injury from progressing to long-term
disability
• e.g. newborn screening for metabolic
disorders followed by dietary restrictions to
prevent damage to the nervous system;
effective emergency medical care for head
injury
 Tertiary Level of Prevention
• rehabilitation and special educational
services to mitigate disability and improve
functional and participatory or social
outcomes once disability has occurred
• e.g. rehabilitation of post-stroke patients
PRIMARY SECONDARY TERTIARY
 Nutrition

Gavino Ivan N. Tanodra, MD, RPh

 Objectives
• To know the importance of breastfeeding
 Nutrition
• Proper intake and utilization of foods
 Nutrients
• chemical substances found in food that
are needed for life
• Over 40 different nutrients needed by the
body for growth, reproduction and
maintenance of tissue and body
regulations
 Nutrients
• Six basic categories of nutrients –
proteins, carbohydrates, lipids,
vitamins, minerals and water
• Dietary Reference Intakes (DRI) –
generic terms to refer to four different sets
of data e.g. RDA, EAR, AI, UL
• Recommended Dietary Allowance
(RDA) – have been recognized universally
as the standards for levels of nutrients
recommended in our diet
• Estimated Average Requirements
(EAR) – is the intake that meets the
estimated nutrient needs of half of the
individuals in a specific stage and gender
group
• Adequate Intake (AI)- used when
sufficient scientific evidence is unavailable
to estimate an average requirement
• Tolerable Upper Intake Level (UL) –
used to indicate the maximum intake by an
individual that is unlikely to pose risks of
adverse health effects in almost all healthy
individuals in a specified group
Elements

Vitamins

Macronutrients

Electrolytes and water

 Elements
Arsenic Manganese
Boron Molybdenum
Calcium Nickel
Chromium Phosphorus
Copper Selenium
Fluoride Zinc
Iodine
Iron
Magnesium
 Vitamins
Biotin Vitamin A
Choline Vitamin B6
Folate Vitamin B12
Niacin Vitamin C
Pantothenic acid Vitamin D
Riboflavin Vitamin E
Thiamine Vitamin K
Lack of Vitamins and Minerals
Lack of Vitamins and Minerals
Lack of Vitamins and Minerals
 Macronutrients
• Carbohydrates
• Total fiber
• Total fat
• N-6-polyunsaturated fatty acids (linoleic
acid)
 Macronutrients
• N-3-polyunsaturated fatty acids (alpha
linoleic acid)
• Saturated and trans fatty acids &
cholesterol
• Protein and 22 amino acids
 Proteins
• Essential amino acids – PVT TIM HALL
 RDA is dependent on the ff:
• Age
• Gender
• Activity (sedentary, low active, active, very
active)
• Pregnancy/Lactation (for women)
• Co-morbities (diabetes, hypertension,
enzyme deficiencies, renal problems)
Nutritional Status of Various Age Groups: Philippines,
2003 FNRI-DOST

Among 0 – 5 years old children, 27.6% are underweight,

30.4% are short, 5.5% are thin, and 1.4% are overweight.

Among 6 – 10 years old children, 26.7% are underweight,

36.5% are short, and 1.3% are overweight.
Nutritional Status of Various Age Groups: Philippines,
2003 FNRI-DOST

Among 11 – 19 years old preadolescents and adolescents,

15.5% are underweight, and 3.5% are overweight.

Among these age groups, undernutrition has decreased while

overweight increased between 1998 and 2003.

Among pregnant and lactating women, 26.6% and 11.7%,

respectively, are underweight.
Nutritional Status of Various Age Groups: Philippines,
2003 FNRI-DOST

Among adults, 12.3% are Chronic Energy Deficient (CED) and

23.9% are overweight to obese

The prevalence of overweight and obesity in 2003 has increased

from 1998

Public health and clinical risk to co-morbidities is moderate to high

in 36% of the 20 – 39 year-olds, 48.9% of the 40 – 59 year-olds,
and 34.9% of the elderly (60 years of age and over)
Nutritional Status of Various Age Groups: Philippines,
2003 FNRI-DOST

The prevalence of anemia among 6 months to < 1 y and 1 y

and 11 months old children has remained unabated and
continued to increase, and is presently alarmingly high at
66% and 53.0%, respectively

Among pregnant and lactating women, anemia remains a

public health problem with 43.9% and 42.2% prevalence,
respectively
 Objectives of a Nutrition
Program
Reduction in:
a. Underweight among pre-school children
b. Stunting among pre-school children
c. Chronic energy deficiency (CED) among
pregnant women
 Objectives of a Nutrition
Program
Reduction in:
d. Iron deficiency (IDA) among children 6
months to 5 years old, pregnant and
lactating mothers
e. prevalence of overweight, obesity and
non-communicable diseases
 Objectives of a Nutrition
Program
Reduction in:
f. reduction in the prevalence of iron
deficiency disorder among lactating
mothers
g. elimination of moderate & severe iodine
deficiency disorder among school children
and pregnant women
h. reduction in the prevalence of low birth
weight
 Determination of Stunting and
Underweight in Children/Teens
• Weight for age (Boys/Girls)
• Height for age (Boys/Girls)
 Stunting
• Stunting – defined when the child’s height
fall below 5th percentile of the reference
population in height for age curve;
consider genetic predisposition first if both
parents are short
• > 5% of children are below the 5th
percentile = higher than expected
prevalence of stunting in the community
 Underweight
• Underweight (< 20 years old) is defined if
the child / teen’s weight fall below the 5th
percentile of the reference population
weight for age curve
 Chronic Energy Deficiency
• "steady state" where an individual is in
energy balance, i.e. the energy intake
equals the energy expenditure, despite the
low body weight and low body energy
stores
 Chronic Energy Deficiency
• Thus, by never growing to a normal size or
having experienced one or more stages of
energy deficiency, the individual has
arrived at a reduced body weight with
possibly limited physical activity, which
have allowed the energy demands of a
lower basal metabolic rate (BMR) and
reduced amounts of activity to balance the
lower intake
 Common Nutritional
Deficiencies in the Philippines
• Protein Energy Malnutrition
• Iron Deficiency Anemia
• Vitamin A Deficiency
• Iodine Deficiency Disorders
 Common Nutritional
Deficiencies in the Philippines
• Protein Energy Malnutrition (PEM) – a
lack of energy and protein which results
in growth retardation
 Marasmus
• Derived from a word meaning withering or
wasting
• Due to diet very low in calories (CHO, fats
and proteins)
• Balanced Starvation
 Marasmus
• Result of unsuccessful breastfeeding or
insufficient breastmilk supply with little or
no other food given
• Breastfeeding may be given scheduled or
per demand
 Marasmus
• emaciated
• Face become shrunken (old man’s face)
• Muscle wasting best seen and felt at the
buttocks, thighs, upper arms, and scapular
region
Marasmus
 Kwashiorkor
• Derived from the African language
meaning “the sickness of the older child
when the next baby is born”
• Corresponds to the weaning time of the
older child
 Kwashiorkor
• Deficiency of PROTEIN with adequate or
excess in calories
• Usually occur in a breastfed child until he
is weaned into starchy diet, without high
protein foods
• Highly probable that deficiency of other
nutrients (Vit A and B Complex) are
frequent contributing factors
 Kwashiorkor
• Edema – cardinal sign (should not be
diagnosed in its absence)
• First detected at the ankles until it
becomes generalized
• Marked on the subcutaneous tissues of
the dependent parts (legs, forearms,
penis, scrotum, lower back, and lower face
 “moonface”)
 Kwashiorkor
• Protruding abdomen is due edema as a
result of hypotonia
• Muscle wasting can be demonstrated
functionally by testing the infants ability to
hold his head when gently pulled from a
lying to a sitting position
 Kwashiorkor
• Psychomotor changes
looks miserable and does not smile
motor development is retarded
irritable
 Kwashiorkor
• Common signs
a. Hair changes - long, scanty, pluckable,
FLAG SIGN- alternating light and dark bands
indicate periods of protein adequacy and
deprivation

b. Depigmentation of the skin

c. Anemia
 Kwashiorkor

Flaky paint rash or Enamel Dermatosis

 Protein Energy Malnutrition
Marasmus Kwashiorkor
• Muscle Wasting • Poor appetite
• Growth Retardation • Diffuse depigmentation
• Apathetic, Quiet • Diarrhea
• Good Appetite • Flakypaint/ enamel
• Diarrhea dermatosis
• Moonface
• Hepatic Enlargement
 Non-Infectious Diarrhea
Malnutrition  atrophy of the intestinal villi
which contains the brush border  enzyme
lactase is secreted in the outermost layer
of the brush border  lactose
malabsorption  severe cases sucrase
and maltase  TOTAL DISSACHARIDE
INTOLERANCE
 Common Nutritional
Deficiencies in the Philippines
• Iron Deficiency Anemia (IDA) – deficiency
wherein hemoglobin concentration is
below normal level which results in short
attention span, reduced ability to learn and
irritability
 Common Nutritional
Deficiencies in the Philippines
• Vitamin A Deficiency (VAD) – lack of Vit A
that may result to nightblindness (inability
to see in dim light), xerophthalmia
(dryness of the eyes), photophobia
(sensitive to bright light), total blindness,
rough dry skin and membranes of the
nasal mucosa, low body resistance and
poor growth
Vitamin A Deficiency
 Common Nutritional
Deficiencies in the Philippines
• Iodine Deficiency Disorders (IDD) – lack
of iodine in the body which results in
goiter, mental retardation, deaf mutism,
difficulty in standing or walking normally
and stunting of the limbs
 Interventions
• Essential maternal and child health service
package (breastfeeding, complementary
feeding, micronutrient supplementation)
• Nutrition, information, communication &
education
• Home, school, and community food
production
 Interventions
• Food assistance includes center based
complementary feeding for wasted and
stunted children and pregnant women with
delivering low birthweight (< 2,500 g)
• Livelihood assistance
 DIETARY MANAGEMENT OF
MALNOURISHED CHILD
• The essence of dietary management is to
give the child HIGH CALORIC, HIGH
PROTEIN DIET aiming at 100 – 200 cal/kg
BW/ day
• 48 gm protein/kg BW/ day
• mode: feed frequently
 DIETARY MANAGEMENT OF
MALNOURISHED CHILD
• Starting them on a full diet will definitely
cause a relapse of their diarrhea
• NPO for 24 – 48 hours – IVF

• 50 – 75 cal/kg/day
2 gm/kg/day of protein
• No bouts of diarrhea
 DIETARY MANAGEMENT OF
MALNOURISHED CHILD
• Increase 200 mg/day of calories
• Increase protein 8gm/day

• Until weight gain is OPTIMAL (24 weeks)

• Maintain CHO = 110 – 120 cal/kg/day

• PROTEIN = 4 – 8 gm/BW/day
• PROGNOSIS: most of the clinical features
and pathologic changes are REVERSIBLE
but if SEVERE malnutrition occurs early in
life, specially before 6 months of age,
when psychomotor and brain development
is critical the changes noted maybe
IRREVERSIBLE.
 DOH Programs
• Food Fortification (Republic Act 8976)
• Micronutrient Supplementation (Araw ng
Sangkap Pinoy / Garantisadong Pambata /
Child Health Week)
 Food Fortification Program
RA 8976
• Republic Act 8976 or the Food Fortification
Act of 2000 was signed into law on
November 7, 2000 for full implementation
on November 7, 2004, to address the
problem of micronutrient malnutrition
• .
 Food Fortification Act
RA 8976
• This law is complimentary to RA 8172 or
the ASIN Law (An Act Promoting Salt
Iodization Nationwide), passed in
December 1995, mandating the iodization
of all salt sold in the country
 Food Fortification Program
RA 8976
• The Philippine Food Fortification Program
shall cover all imported or locally
processed foods or food products for sale
or distribution, for human consumption in
the Philippines
 Sangkap Pinoy
• a term used by the DOH for micronutrients
added to food to enhance its nutritional
quality

• These micronutrients are vitamin A, iron

and iodine, which cannot be synthesized
by the human body, and therefore must be
provided through the diet
 Sangkap Pinoy
• The intake of these micronutrients through
the Filipino diet is often inadequate and is
responsible for the micronutrient
malnutrition afflicting a majority of the
population.
Sangkap Pinoy
• Sangkap Pinoy Seal (SPS) is
a mark of DOH recognition of a
food product that is properly
fortified with either vitamin A,
iodine or iron or a combination
of these micronutrients and
that complies with regulations
of the Bureau of Food & Drug
(BFAD) of the DOH for quality,
labeling and addition of
fortificants.
Examples of Products
 Diamond Sangkap Pinoy
• In 2004, the Diamond Sangkap Pinoy Seal
was introduced to be used solely for staple
products mandated for fortification, namely
cooking oil, wheat flour, rice, refined sugar
and salt.
• Currently there are 71 products under the
Diamond SPS
Example of Products
 Garantisadong Pambata
• a campaign to support various health
programs to reduce childhood illnesses
and deaths by promoting positive child
care behaviors
• A program of the Department of Health in
partnership with the Local Government
Units and other government and
nongovernment organizations
 Garantisadong Pambata
• done twice a year one week in April and
one week in October.
• Second week of October was designated
as "Garantisadong Pambata" week.
 Garantisadong Pambata
• Giving Vitamin A capsules (VAC)
supplement to all 12-59 months old
children.
• Catch up immmunizations (children who
missed the routine immunizations like
BCG, OPV, DPT, Measles)
• Distribution of iron supplements to infants
and pregnant women
 Garantisadong Pambata
• Promotion of child positive caregiving
behaviors like
Exclusive breastfeeding of infants from 0-6months
old
Feeding infant micronutrient rich complementary
foods starting 6 months old,
Use of iodized salt daily
Buying and eating fortified foods,
Brushing of teeth properly and regularly
Letting children play safe toys
No smoking in front of preschooler
 Awareness and Usage of Fortified Foods
FNRI-DOST 2004

• Ninety-seven percent of households consume

foods with the Sangkap Pinoy Seal, even as only
16% know what the Sangkap Pinoy Seal is

• Eighty percent of households (mothers) claim

they are aware of iodized salt, but only 38%
actually use iodized salt. The proportion of
households whose salt tested positive for iodine
is 56.4%
 Awareness and Usage of Fortified Foods
FNRI-DOST 2004

• The most commonly consumed fortified foods in the

market today, by households, children as well as pregnant
and lactating women are instant noodles and sardines
CONCLUSIONS

• There has been a general improvement between

1998 and 2003 in the country’s overall nutrition
situation, affecting various population groups, as
evidenced specifically by reductions in
underweight and stunting among 0- 5 and 6 – 10
years old children, reduction in underweight
among pregnant and lactating women, and
reduction in CED among adults

• There is however a trend towards increasing

overweight among adults as well as among
children
CONCLUSION

• The anemia problem, especially among infants from 6

months to less than a year old, toddlers 1 y to 1 y and
11 months old, and pregnant and lactating women
have remained unabated

• Considering the targets set for 2004 in the MTPPAN

and the Medium Development Goals set for 2015,
overall efforts to reduce Protein-Energy Malnutrition,
Chronic Energy Deficiency, Nutritional Anemia as well
as arrest the increasing trend of overweight and
obesity will need to be strengthened

• A national policy on iron supplementation for infants

and young children should be put in place.
Breastfeeding and Child
Feeding
Gavino Ivan N. Tanodra, MD RPh
Infant and Young Child Feeding
• Global Strategy for Infant and Young Child
Feeding (IYCF) issued jointly by the WHO
and UNICEF in 2002
• Endorsed by concensus in the 55th World
Health Assembly in May 2002 and
UNICEF Executive Board in September
2002
 Key Messages
• Initiate breastfeeding one hour after birth
• Exclusive breastfeeding for the 1st 6
months of life (vitamins, mineral
supplements, medicines permitted)
• Complementary feeding at 6 months with
appropriate foods excluding milk
supplements
• Extend breastfeeding up to 2 years and
beyond
 Benefits of Breastfeeding in
Children
• Safely rehydrates and provides essential
nutrients to a sick child especially those
suffering from diarrheal disease
• Strengthens the immune system
• Increase IQ points
• Psychological Benefits
 Benefits of Breastfeeding in
Mothers
• Reduces woman’s risk of excessive blood
loss after birth
• Provides natural methods of delaying
pregnancy
• Reduces the risk of ovarian/breast cancer
and osteoporosis
Benefits of Breastfeeding in the
Community
• Conserve funds that would be otherwise
spent for milk substitutes
• Saves medical cost to families and
government by preventing illnesses and
providing immediate postpartum and
contraception
 Give colostrum to the baby
• Prepares the baby’s stomach to digest
milk
• Contains antibodies against infection
• Does not cause tummy ache or diarrhea
• DO NOT give plain water, sugared water,
chewed sticky rice, herbal preparations or
starve the baby while waiting for the milk
to come in
• May cause digestion problems and
infection in the baby and will decrease the
mother’s milk production
• Use both breasts alternately at each
feeding
• Prevent engorgement and infection
 Rooming In and Breastfeeding
Act of 1992
• Requires both public and private health
institutions to promote rooming-in and to
encourage, protect and support the
practice of breastfeeding
• Provision of a human milk bank
 Lactose Intolerance
• Due to lack of enzyme (lactase)
• 80% of malnourished children
• Intake of regular milk promotes diarrhea
 Confirmation of Lactose
Intolerance
• Aspirate watery portion from feces
• Test for pH (<6) and reducing substance
(trace to +1)
 How to re-introduce milk
feedings
• After 2-3 days without milk, a very dilute
milk preparation is introduced gradually
1 part milk:7 parts water --1:6 (after 1-2
days) -- 1:2
• To increase caloric content, may add pure
glucose or sucrose
 How to re-introduce milk
feedings
• Give NON-LACTOSE formula:
Al 110 – glucose
Isomil and Nutratigen – sucrose
Sobee – dextrimaltose
Nursoy – soya
Complementary feeding
 Complementary foods should
be:
• Timely – introduced when the need for
energy and nutrients exceed what can be
provided through exclusive and frequent
feeding
• Adequate – provide sufficient energy,
protein and macronutrients to meet
growing child’s nutritional needs
 Complementary foods should
be:
• Safe – hygienically stored and prepared
and fed with clean hands using clean
utensils
• Properly fed – given consistent with a
child’s signals of hunger and that meal
frequency and feeding methods are
suitable for the child’s age
 Low birth weight babies
• < 2,500 g – premature, term, small for
gestational age
• Often very hungry and should be more
often breastfed than larger babies so they
could catch up
• Those having difficulty sucking can be fed
by tube or cup and establish breastfeeding
later
 Fluid needs
• Enough in exclusively breastfed babies
• When other foods are added, the baby
may need extra fluids
• < 6 mos receiving milk replacements is
enough
• Extra fluid is given for fever and diarrhea
 Fluid needs
• Water is good for thirst, pure juices can
also be used
• Too much fruit juice may cause diarrhea
and reduce child’s appetite for food
• Drinks that contain a lot of sugar can make
the child thirstier
• Sodas are not suitable for young children
 Fluid needs
• Teas and coffees reduces iron that is
absorbed from food (not be given the
same time or within 2 hours before and
after food)
• Drinks should not replace foods or
breastfeeding
 Fluid needs
• Non-breastfed child (6-24 mos) needs
approximately 4-6 cups of water per day in
a hot climate
 Feeding the ill child
• Encourage the child to drink and eat with
lots of patience
• Feed small amounts frequently
• Give food that the child likes
• Give a variety of nutrient rich foods
• Continue breastfeeding and more
frequently
 Feeding the child during
recovery
• Child’s appetite usually increase after
illness which gives an opportunity for extra
feeding to allow the child to catch up with
growth
Thank you!
 22 Amino acids

1. Alanine 12. Isoleucine - Essential

2. Arginine 13. Leucine - Essential
3. Asparagine 14. Lysine - Essential
15. Methionine - Essential
4. Aspartic acid 16. Phenylalanine - Essential
5. Cysteine 17. Proline
6. Cystine 18. Serine
7. Glutamine 19. Threonine - Essential
8. Glutamic acid 20. Tryptophan - Essential
9. Glycine 21. Tyrosine
10. Histidine 22. Valine - Essential
11. Hydroxyproline