2Dietary Reference Intakes Collective term which includes four values: EAR Estimated average requirement RDA Recommended dietary allowance AI Adequate Intake UL Upper Intake Level
3Estimated average requirement Average daily nutrient intake estimated to meet the requirement of half the healthy (& assume intake of other nutrients are adequate) individuals in a particular age (life stage) and gender group.Meet the requirement -maintain normal function and health
4How are requirements estimated Observation of population groups- intakes associated with absence of deficiency signs.Intakes needed to maintain balance (e.g. nitrogen balance studies for protein).Depletion-repletion studies- intakes needed to prevent deficiency (clinical or biochemical changes)
5How are requirements estimated Intakes needed to maintain circulating levels of nutrient or tissue concentration (tissue saturation)Intakes associated with biological markers of adequacy - functional adequacy e.g enzyme activity
6Recommended Dietary Allowance Average daily nutrient intake that is enough (or more than enough) to meet the requirement of 97-98% of the healthy individuals in a particular age (life stage) and gender groupTo determine need EAR and variability (SD) of EAR (assume distribution of requirements is normal)RDA = EAR + 2 SD
7Adequate Intake Used when insufficient information to determine RDA recommended average daily nutrient intake based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups ) of apparently healthy persons that are assumed to be adequate
8Tolerable Upper Intake Level highest average daily intake likely to pose no risk of adverse health effects to almost all individuals in the life stage and gender group.As intake exceeds UL potential risk of adverse effects increaseNeed for this value came from increased fortification of foods and use of supplements
171 ounce of ready to-eat cereal WHAT COUNTS AS A SERVING? Food GroupsBread, Cereal, Rice, and Pasta1 slice of bread1 ounce of ready to-eat cereal1/2 cup of cooked cereal, rice, or pastaVegetable1 cup of raw leafy vegetables1/2 cup of other vegetables, cooked or raw3/4 cup of vegetable juiceFruit1 medium apple, banana, orange1/2 cup of chopped, cooked, or canned fruit3/4 cup of fruit juiceMilk, Yogurt, and Cheese1 cup of milk or yogurt1-1/2 ounces of natural cheese2 ounces processed cheeseMeat, Poultry, Fish, Dry Beans, Eggs, and Nuts2-3 ounces of cooked lean meat, poultry, fish1/2 cup of cooked dry beans or ½ cup tofu counts as a serving. 2 tablespoons of peanut butter or 1/3 cup of nuts count as 1 ounce of “meat” according to the USDA.The USDA Food Guide Pyramid offers a booklet with their educational materials and they have established what they want to call a serving to allow for countable “units” for adding up total servings. The chart lists typical serving sizes according to the USDA.
18Exchange Lists Categories Starch (80 kcal)15 grams carbohydrate3 grams protein0-1 grams fatVegetable (25 kcal)5 grams carbohydrate2 grams protein0 grams fatThis slide lists the energy nutrient values for the starch and vegetable exchange. The chart in the Moore book shows the exchange categories, the energy nutrients of each category, and sample food plans to meet these needs.
19Exchange Lists Categories Fruit (60 kcal)15 grams carbohydrate0 grams protein0 grams fatProtein- legumes, meats, cheeses ( kcal)0 grams carbohydrate7 grams protein1-8 grams fat (depending on whether food is very lean, lean, medium fat or high fat)The energy nutrient values are given in this slide for the fruit and protein exchange categories.
20Exchange Lists Categories Milk ( kcal)12 grams carbohydrate8 grams protein0-8 grams fat (depending on amount of fat in milk)Fat (45 kcal)0 grams carbohydrate0 grams protein5 grams fatThe energy nutrient values are given in this slide for the milk and fat exchanges.The final tool for helping oneself to meet nutrient needs is to assess, evaluate, then adjust one’s diet with the help of a computer dietary analysis. The diet analysis program packaged with this book can help one to take all of this information about essential nutrient requirements and design a personalized program for one’s individual needs. This process is ongoing and an important ingredient in achieving optimal nutrition for a lifetime.
21SAMPLE DIETS FOR A DAY AT 3 CALORIE LEVELS Low 1,600Mod 2,200High 2,800Grain Group Servings6911Vegetable Group Servings345Fruit Group Servings2Milk Group Servings2-3Meat Group (ounces)7Total Fat (grams)537393Total Added Sugars (teaspoons)1218Women who are pregnant or breastfeeding, teenagers, and young adults to age 24 need 3 servings of Dairy or other Calcium-rich foods. “Meat” group amounts are in total ounces.The USDA has also designed a chart of three sample diets indicating the number of servings corresponding with one’s caloric needs.
22Standards For Food Labeling RDA not used on food label since it is gender and age specificFDA developed the Daily ValuesReference Daily Intake (RDI) for vitamins and mineralsDaily Reference Value (DRV) for nutrients without RDAsOnly used on food labels
24Nutritional Assessment Why? The purpose of nutritional assessment is to:Identify individuals or population groupsat risk of becoming malnourishedwho are malnourished
25Nutritional Assessment Why? 2 To develop health care programs that meet the community needs which are defined by the assessmentTo measure the effectiveness of the nutritional programs & intervention once initiated
26Direct Methods of Nutritional Assessment These are summarized as ABCDAnthropometric methodsBiochemical, laboratory methodsClinical methodsDietary evaluation methods
27Anthropometric Methods Anthropometry is the measurement of body height, weight & proportions.It is an essential component of clinical examination of infants, children & pregnant women.It is used to evaluate both under & over nutrition.The measured values reflects the current nutritional status & don’t differentiate between acute & chronic changes .
28Other anthropometric Measurements Mid-arm circumferenceSkin fold thicknessHead circumferenceHead/chest ratioHip/waist ratio
29Anthropometry for children Accurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child.For growth monitoring the data are plotted on growth charts over a period of time that is enough to calculate growth velocity, which can then be compared to international standards
30Measurements for adults Height:The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault & height is recorded to the nearest 0.5 cm.
31WEIGHT MEASUREMENTUse a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable.Weigh in light clothes, no shoesRead to the nearest 100 gm (0.1kg)
32Nutritional Indices in Adults The international standard for assessing body size in adults is the body mass index (BMI).BMI is computed using the following formula: BMI = Weight (kg)/ Height (m²)Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity & mortality
34Waist/Hip RatioWaist circumference is measured at the level of the umbilicus to the nearest 0.5 cm.The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together.The measurement should be taken at the end of a normal expiration.
35Waist circumferenceWaist circumference predicts mortality better than any other anthropometric measurement.It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identifiedMALES FEMALELEVEL > 94cm > 80cmLEVEL > 102cm > 88cm
36Waist circumference/2Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no further weight gain.Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes & CVS complications.
37ADVANTAGES OF ANTHROPOMETRY Objective with high specificity & sensitivityMeasures many variables of nutritional significance (Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI).Readings are numerical & gradable on standard growth chartsReadings are reproducible.Non-expensive & need minimal training
38Limitations of Anthropometry Inter-observers errors in measurementLimited nutritional diagnosisProblems with reference standards, i.e. local versus international standards.Arbitrary statistical cut-off levels for what considered as abnormal values.
39DIETARY ASSESSMENTNutritional intake of humans is assessed by five different methods. These are:24 hours dietary recallFood frequency questionnaireDietary history since early lifeFood dairy techniqueObserved food consumption
4024 Hours Dietary RecallA trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours.It is quick, easy, & depends on short-term memory, but may not be truly representative of the person’s usual intake
41Food Frequency Questionnaire In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency & quantity) per day, per week & per month.inexpensive, more representative & easy to use.
42Food Frequency Questionnaire/2 Limitations:long QuestionnaireErrors with estimating serving size.Needs updating with new commercial food products to keep pace with changing dietary habits.
43DIETARY HISTORYIt is an accurate method for assessing the nutritional status.The information should be collected by a trained interviewer.Details about usual intake, types, amount, frequency & timing needs to be obtained.Cross-checking to verify data is important.
44FOOD DAIRYFood intake (types & amounts) should be recorded by the subject at the time of consumption.The length of the collection period range between 1-7 days.Reliable but difficult to maintain.
45Observed Food Consumption The most unused method in clinical practice, but it is recommended for research purposes.The meal eaten by the individual is weighed and contents are exactly calculated.The method is characterized by having a high degree of accuracy but expensive & needs time & efforts.
46Initial Laboratory Assessment Hemoglobin estimation is the most important test, & useful index of the overall state of nutrition. Beside anemia it also tells about protein & trace element nutrition.Stool examination for the presence of ova and/or intestinal parasitesUrine dipstick & microscopy for albumin, sugar and blood