1. Nutrition (NUTN 204) A HMAD ALBALAWI SENIOR SPECIALIST IN NUTRITION Lecturer Faculty of Applied Medical Sciences Department of Nursing

2. My Webpage and Email Ahmad albalawi: Department of Clinical Nutrition Webpage – http://www.ut.edu.sa/ar/web/u014451/courses http://www.ut.edu.sa/ar/web/u014451/courses Contact email – ah.albalwi@ut.edu.sa ah.albalwi@ut.edu.sa

3. Outlines Definition of nutrition Importance of nutrition to health Overview of types of nutrients Nutrition Care Process 3

4. What is Nutrition? the science of foods and the nutrients and non-nutrients in food and the body’s mechanism of using these nutrients including ingestion, digestion, absorption, transport, metabolism, interaction, storage and excretion a broader definition includes the social, societal/economic, cultural, psychological, and environmental implications of food and eating 4

5. What is Nutrition? In hospitals, nutrition may refer to the food requirements of patients, including nutritional solutions delivered via an IV (intravenous) or IG (intragastric) tube 5

6. What is Nutrition? “the science of food, the nutrients and the substances therein, their action, interaction, and balance in relation to health and disease, and the process by which the organism ingests, absorbs, transport, utilizes, and excretes food substances” (The Council on Food and Nutrition of the American Medical Association) 6

7. What is Nutrition? Nutritional science studies how the body breaks food down (catabolism) and repairs and creates cells and tissue (anabolism) catabolism and anabolism = metabolism Also examines how the body responds to food. In other words Nutritional science investigates the metabolic and physiological responses of the body to diet 7

8. IMPORTANCE OF NUTRITION TO HEALTH 8

9. Nutrition… more focused on the steps of biochemical sequences through which substances inside us and other living organisms are transformed from one form to another - metabolism and metabolic pathways 9

10. Nutrition… involves identifying how certain diseases, conditions or problems may be caused by dietary factors – poor diet (malnutrition) – food allergies – metabolic diseases 10

11. OVERVIEW OF TYPES OF NUTRIENTS 11 Macronutrients (organic): Carbohydrates Protein fat Micronutrients Vitamins ( organic) Minerals (inorganic) Water Hint: organic compounds contain carbon with carbon- hydrogen bonds, while inorganic may contain carbon and other metal elements but with no carbon-hydrogen bonds (Difference Between. Info, 2014)

12. Nutrition Care Process 12

13. Nutrition Assessment: Registered Nutritionists (RN) and Dieticians (RD) collect documents regarding the patient such as nutrition- related history, anthropometric measurements, biochemical results and client history Diagnosis: Nutrition assessment will provide data to RD that guides them to select the appropriate nutrition diagnosis ( for example, naming the specific problem) Intervention: Intervention will be directed by RD to the root of the cause of the nutrition-related disease or problem and aimed at reducing the symptoms of and signs of the diagnosis Monitoring/Evaluation: The final step of the process is monitoring and evaluation, which the RD sees whether the patient/ client has achieved or is in-progress towards the planned goals (Eat Right Academy of Nutrition and Dietetics, 2014) 13

14. Question Define Nutrition? 1.It only focuses on metabolic reactions in the body 2.It only focuses on the metabolism of certain diseases in the body 3.It focuses on metabolic reactions, how food substances work in the body, and diseases that are related to diet 4.Non of the above Everyone please answer the question by writing the number of the choice you see correct above 14

15. References Willett, WC. Overview and perspective in human nutrition. Asia Pac J Clin Nutr 2008;17(S1): 1-4. 15

16. Nutrition (NUTN 204) Nutritional Health Assessment A HMAD ALBALAWI., M ASTER OF NUTRITION Lecturer Faculty of Applied Medical Sciences Department of Nursing

17. Outlines Historical information Food Intake Data Anthropometric Data – Ideal body weight – Body Mass Index – Computation of BMI – BMI Classification – Skin-fold Measurements – Waist to Hip Ratio – Mid Upper Arm Circumference (MUAC) – Stadiometer – Desirable body weight Implementing Nutrition Care – Energy Requirement 17

18. Historical Information – information about a person’s history with respect to health status, socioeconomic status, drug use, and diet – reflects a person’s medical record and may reveal a disease that interferes with the person’s ability to eat or the body’s use of nutrients – Also reflects person’s family history of major diseases 18

19. Historical Information 1930 to 1959, nutritional assessment was used in designed surveys to describe the nutritional status of populations on a national basis During 1950s, the importance of nutritional assessment had been noticed, and awareness had been increased among physicians and surgeons regarding the relationship between nutritional status and well-being In 1970s, the assessment of the nutritional status of hospitalized patients have been developed for those who live in developing regions (Sando and Okada, 1998)

20. Food Intake Data examines a person’s intake of foods, beverages, and supplements may reveal either a surplus or inadequacy of nutrients or energy – How is it done? Record the foods the person has eaten over a period of 24 hours (24-hour recall), 3 days or a week Ask what food the person typically eats and how much each Days in the record must be typical of the person’s diet Determine the nutrition consumed (based from food composition 20

21. Food Intake Data

22. Obesity in saudi arabia: – Prevalence of overweight in Saudi Arabia is around 36% (17232 subjects) – Prevalence of obesity is 35.5% (17232 subjects) (Alnozha et al, 2010) According to Al-rethaiaa, Fahmy and Al-shwaiyat, 2010, students in Saudi are 21.8% overweight and 15.7% obese. The study included 357 participants who were studying at Alqassim University

23. Anthropometric Data

24. Reveals nutrition problem by taking height weight and comparing the person’s measurements with standards specific for gender and age or with previous measures Taken periodically to reveal patterns May reveal problems such as growth failure in children, wasting or swelling of body tissues and obesity 24

25. Ideal body weight Indicates a person’s body composition has a good balance of lean body mass and fat tissue importance: it is used to major whether or not a person is at risk of nutritional-related diseases such as heart and cardiovascular diseases (National Heart, Lung and Blood Institute)

26. Body Mass Index The weight in kilograms (kg) divided by the square of the height in meters (describes relative weight for height) BMI = weight (kg) ÷ height (m 2 )

27. Computation of BMI Joe is 5 feet 10 inches tall and weighs 172 lb. Step 1 Convert weight into kg – 172 lb ÷ 2.2 lb/kg = 78.18  78.2 kg Step 2 Convert height into meters – 5’10” = 70” (5’ x 12 (constant)” = 60” + 10” =70”) – 70” x 2.54 (constant) cm/in =177.8 cm – 177.8 cm ÷ 100 cm = 1.8 m – 1.8 m 2 = 3.24  3.2 m (1.8 x 1.8 = 3.24) Step 3 Calculate BMI – 78.2 ÷ 3.2 = 24.43

28. BMI Classification ClassificationBMI Underweight<18.5 Normal18.5 – 24.9 Overweight25.0 – 29.9 Obesity≥30.0

29. Skin-fold Measurements Facts: 1.Half of total body fat is directly under the skin 2.Skin-fold measurement is not used to assess or monitor weight status 3.Multiple sites should be measured

30. Percent Body Fat ClassificationAppearanceMenWomen Very Low FatSkinny7-1014-17 Low FatThin10-1317-20 AverageNormal13-1720-27 Above NormalPlump17-2527-31 Very HighFat>25>31

31. Waist to Hip Ratio Abdominal ratio To measure body fat distribution and adiposity Formula: Waist/ hip circumference Waist is measured at the narrowest point under the last rib Hip is measured at the widest point of the buttock

32. Waist-to-Hip Ratio Guide in evaluating health risk

33. Waist to Hip Ratio Formula: Waist circumference (cm) Hip circumference (cm) For men more than 102cm of the waist circumference is considered obese For women more than 88cm of the waist circumference is considered obese > 1 in men = obesity > 0.85 in women =obesity

34. Mid Upper Arm Circumference (MUAC) It evaluate fat stores It measures the arm, muscle mass, subcutaneous fat and bone It estimates wasting of an individual Steps: Use a measuring tape Allow the subject to sit and hang his arm on the side Mark the midpoint Place the tape around the mid upper arm Measure 3 times (nearest cm) Average the 3 measurements

35. Mid Upper Arm Circumference (Children 1- 5) MUAC Level of nutrition > 14 Normal 12.5 - 14 Mild / moderate malnutrition < 12.5 Severe malnutrition

36. Mid Upper Arm Circumference (Adults) MUAC Level of nutrition Male: > 23 Normal < 23 Malnourish Female: > 22 Normal < 22 Malnourish

37. Stadiometer Height A linear measurement Indication of past or chronic nutritional status

38. How to obtain correct height measurement? Infantometer for infants

39. How to obtain correct height measurement? Stadiometer for children and adults

40. How to obtain correct height measurement? Infants:

41. How to obtain correct height measurement? Children and adults:

42. How to obtain correct height measurement? Knee Height To estimate stature of the patients whose standing height cannot be taken accurately Bent the knee to a 90 degree angle

43. How to obtain correct height measurement? Knee Height Measure by using a tape measure, from the knee cap to the tibia Make at least 2 readings Get the knee height in cm Formula Men: 64.19 – (0.04 x age in years) + (2.02 x knee height in cm) Women: 84.88 – (0.24 x age in years) + (1.83 x knee height in cm)

44. Desirable body weight 44

45. Desirable Body Weight (Infants) Based on birth weight and age First 6 months: DBW = Birth weight (gm) + (age in mo. X 600) 7 months – 1 year: DBW = Birth weight (gm) + (age in mo. X 500)

46. Desirable Body Weight (Infants) Based on age DBW (k) = (age in mo./2) + 3

47. Desirable Body Weight (Children) DBW (k) = (age in years x 2) + 8

48. Desirable Body Weight (Teens & Adults) Tannhauser’s / Broca Index Method: DBW (k) = height (cm) – 100

49. Desirable Body Weight (DBW) for Teens & Adults BMI derived formula Formula: Men: DBW (k) = height in meters² x 22 Women: DBW (k) = height in meters 2 x 20.8 IBW and ABW: http://www.manuelsweb.com/IBW.htm

50. Desirable Body Weight (Amputees) Formula: Compute DBW Adjust DBW according to type of amputation Adjusted DBW = DBW (DBW x % total wt. amputated)

51. Desirable Body Weight (Amputees) Body part % of total body weight Hand0.3 Forearm and hand 2.6 Entire arm 6.2 Foot1.7 Below knee amputation 7.0 Above knee amputation 11.0 Entire leg 18.6

52. Implementing Nutrition Care

53. Energy Requirement Total Energy Requirement (TER): – For muscular and metabolic activities of the body which requires energy – Energy – comes from oxidation of food – Measured in kilocalories / kilojoules – Consider: age, sex, physical activity and health condition – TER is rounded off to the nearest 50 kcal

54. Total Energy Requirement (Infants) 1 – 6 months TER (kcal /day) = 120 kcals K DBW 7 months – 1 year TER (kcal /day) = 110 kcals K DBW

55. Total Energy Requirement (Children) Narins and Weil TER = 1000 + (100 x age in years) Calorie Needs for age & DBW TER = DBW (k) x calorie allowance accdg to age Age Suggested kcal / k DBW /day 1 – 3 105 4 – 6 90 7 – 9 7 – 975 10 - 12 65 (boys); 55 (girls)

56. Total Energy Requirement (Adolescents) TER = DBW (k) x calorie allowance based on age Age Suggested kcal / k DBW /day 13 – 15 55 (boys); 45 (girls) 16 – 19 45 (boys); 40 (girls) Average 45

57. Total Energy Requirement (Adults) Energy Allowance Based on Activity Level TEA = DBW (k) x Physical Activity Activity level Bed rest (hospital patients) 27.5 Sedentary (mostly sitting) 30.0 Light (Tailor, Nurse, Physician, Jeepney driver) 35.0 Moderate (Carpenter, Painter, Heavy housework) 40.0 Very active (swimming, lumberman) 45.0 45.0

58. Question Calculate your BMI Calculate your desirable body weight by using Tannhauser’s / Broca method 58

59. references Cobiac, L, Dreosti, I & Baghurst, K 1998, Recommended Dietary intakes - is it time for a change? Comm Dept Health & Fam Serv, Canberra Food and Nutrition Board 2003, Dietary reference intakes. Applications in dietary assessment, National Academy of Science. http://books.nap.edu/catalog/9956.html (accessed on 8/1/07) National Health and Medical Research Council, Department of Health and Ageing & Ministry of Health, 2006, Nutrient reference values for Australia and New Zealand: Executive Summary, National Health and Medical Research Council, Canberra Institute of Medicine, 2006, Dietary Reference Intakes. The essential guide to nutrient requirements, National Academy Press Washington DC. (ref QP 141.D54 2006) 59

60. Thank you

61. Food Guides 61

62. Outlines Food Guide Pyramids and the Saudi food and nutritional Palm food exchange list Food labels Food handling and preparation 62

63. Food Guide Adequacy Balance kCalorie (energy) control Nutrient Density Moderation Variety 63

64. adequacy (dietary): providing all the essential nutrients, fiber, and energy in amounts sufficient to maintain health balance (dietary): providing foods in proportion to each other and in proportion to the body’s needs kcalorie (energy) control: management of food energy intake nutrient density: a measure of the nutrients a food provides relative to the energy it provides. The more nutrients and the fewer kcalories, the higher the nutrient density – empty-kcalorie foods: a popular term used to denote foods that contribute energy but lack protein, vitamins, and minerals; potato chips, candy, and colas moderation (dietary): providing enough but not too much of a substance variety (dietary): eating a wide selection of foods within and among the major food 64

65. FOOD GUIDES 65 Include: Nutritional requirements that are based on: Food pyramid and the Saudi food palm

66. Food Guide Pyramid 66

67. 67

68. Food Guide Pyramid Suggests a range of daily servings from each major food group to address under-nutrition and over-nutrition Emphasis on: 1.Variety 2.Balance 3.Moderation 68

69. Food Guide Pyramid 1.Variety: no single food supplies all 40+ necessary nutrients in amounts needed – Helps mitigate the natural toxins and food contaminants by diluting the impact a single food has on overall intake – Ensures adequate intake while minimizing the likelihood of imbalances 2.Balance 3.Moderation 69

70. Question What is the recommended serving amount of carbohydrates per day according to Food Pyramid? – 4 servings per day – 5 servings per day – 6 servings per day 70

71. Exchange food list

72. Diet-planning tools that organize foods by their proportions of carbohydrate, fat, and protein. Foods on any single list can be used interchangeably 72

73. percentage Standards of macronutrients for adults Protein 20% Fat 20% Carbohydrates 60% – Protein gives 4 calories per gram – Fat gives 9 calories per gram – Carbohydrates gives 4 calories per gram

74. Case study Khalid is a regular man (Hieght175cm, weight 82kg). He wants to keep his weight in a normal range. How many grams of Protein, fat and carbohydrates does he need daily if his calories needs are 2000 Kcal?

75. calculation Protein(20%) : – 20/100 *2000= 400/4=100g Fat (20%) – 20/100*2000=400/9=44.4g CHO(60%): – 60/100*2000=1,200/4=300g

76. CaloriesFat (g)Protein (g)Carbs (g) Groups Carbs group 800-1315starch 60--15fruit milk 900-3812Fat- free 1205812Reduced 1508812Whole Varies 15Other carbohydrates 25-25No starchy carbohydrates Meat 350-17-Very lean 5537-Lean 7557-Medium –fat 10087-High-fat 455-Fat group

77. Calories (g) Fat (g) Protein (g) Carbohydrates (g) No. exe 3601524363Milk (low fat) 240--604Fruits 960123612012Starch 125-10255Vegetables 2251535-3 Meat (lean) 13515--3Fat 204557105241Total

78. Food Exchange List 78

79. Food Exchange CalculatorCalculator 79

80. Food Labels What do we get from labels? 1.Nutrient content of the food or beverage 2.Ingredients used 3.Serving size 4.Calories from each nutrient Information which is in grams (g), milligrams (mg), or percentages (%) Food labels are calculated based on adult needs 80

81. Food Handling and Preparation 4 Guidelines in Food Safety 1.Clean — Wash hands and surfaces often 2.Separate — Don't cross-contaminate 3.Cook — Cook to proper temperatures 4.Chill — Refrigerate promptly For more information: http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get- answers/food-safety-fact-sheets/safe-food-handling/basics-for- handling-food-safely 81

82. Food Handling and Preparation Preparation – Always wash hands with warm water and soap for 20 seconds before and after handling food. – Don't cross-contaminate. Keep raw meat, poultry, fish, and their juices away from other food. After cutting raw meats, wash cutting board, utensils, and countertops with hot, soapy water. – Cutting boards, utensils, and countertops can be sanitized by using a solution of 1 tablespoon of unscented, liquid chlorine bleach in 1 gallon of water. – Marinate meat and poultry in a covered dish in the refrigerator. 82

83. Food Handling and Preparation Serving – Hot food should be held at 140 °F or warmer. – Cold food should be held at 40 °F or colder. – Perishable food should not be left out more than 2 hours at room temperature (1 hour when the temperature is above 90 °F). 83

84. Food Handling and Preparation What are the problems that can result from improper food handling and preparation? Food-borne Diseases 1.Campylobacter 2.E. coli 3.Salmonella 4.Norovirus 5.Botulism 6.Listeria 7.Mad-cow disease 8.Ptomaine poisoning 9.Staphylococcus 10.Trichinosis 4 most common causes of food-borne diseases 84

85. References Fight Bac! [homepage on internet]. Canadian Partnership for Consumer Food Safety Education. [Cited 2012 Oct 23]. Available from: http://www.canfightbac.org/cpcfse/en/ http://www.canfightbac.org/cpcfse/en/ Government of Canada. Healthy Canadians: Food Safety and You [Homepage on Internet]. 2010 [cited 2012 Oct 12]. Available from: http://www.healthycanadians.gc.ca/init/sfh-msa- eng.php 85

86. Thank You! 86

87. Research in Nutrition Ahmad Albalawi

88. At the end of the lectures on nutrition research, you should be: Familiar with the types of research used in nutrition Aware of how to make basic interpretations of epidemiological findings Aware of the factors that limit the ability of research to identify the relationship between diet and disease Able to make decisions about the strength of evidence in nutritional science Learning Objectives

89. Types of research used in nutrition Laboratories studies – Advantages and limitations Nutritional epidemiology – Advantages and limitations Level of evidence in nutrition Conclusion Outlines

90. Nutrition Research Laboratory Studies e.g. animal studies e.g. in vitro studies Epidemiology Observational Studies Descriptive Studies e.g. National Surveys Ecological Studies e.g. cross-cultural correlations e.g. migrant studies Analytical Studies e.g. cohort e.g. case control Experimental Studies Clinical trials (Human intervention trials) Community Trials

91. Laboratory Studies e.g. animal and in vitro studies advantages: allow tight control useful for giving ideas about what to study further or for deducing mechanisms of action animal studies useful for establishing levels of safety main limitation: limited relevance to humans

92. Nutritional Epidemiology Epidemiology = study of the nutritional determinants of disease (and other health outcomes) in human populations Observational StudiesExperimental Studies descriptive studies (e.g. National surveys) ecological studies (e.g. cross- cultural correlations, migrant studies) case-control studies cohort studies clinical trails community trials

93. Summary of Epidemiological Studies Descriptivee.g population survey Ecological compare different geographical regions or the same region over time (per capita consumption) Case-control compare people with disease (cases) versus people without the disease (controls) Cohortfollow healthy people over time Nested Case- Control case-control study within an existing cohort Trials researchers intervene at the individual or community level

94. Jargon Busters Exposure Variable believed to be associated with an outcome e.g. poor fibre intake Correlation Relationship between variables Positive – increase exposure, increase outcome Negative – increase exposure, decrease outcome Outcome Health condition, physiological effect, disease etc. e.g. colon cancer

95. Nutritional Epidemiology Strengths: diet-disease relationship often observed at the level of free-living populations can identify associations between exposure and outcomes results can be used to calculate direct estimates of risk

96. Nutritional Epidemiology Limitations: cannot prove cause and effect limited control - potential for many kinds of bias ‘real life’ relevance encourages misuse and over-interpretation of data very effective at discerning strong associations between exposure and outcome but less effective in discerning weaker associations (diet and disease associations are often weak)

97. Strength of Evidence WEAKSTRONGER descriptive ecological case-controlcohort intervention trials in vitro animal case-study

98. There are different types of studies that are considered in nutrition and dietetics Only human relevant studies are considered for nutritional interventions Animal and lab researches are useful for studying mechanisms and reactions of substances Animal studies are less reliable because of their riskiness Conclusion

99. Keli, SO.et al. Fish consumption and risk of stroke. The Zutphen study. Stroke, 1994;23:328-332. Langseth, L. Nutritional Epidemiology: Possibilities and Limitations. ILSI, 1996. Lopez-Carrillo, L. et al. Chilli pepper consumption and gastric cancer in Mexico: a case-control study. American Journal of Epidemiology, 1994;139:263-274. Martinez, ME. et al. Intake of supplemental and total fibre and risk of colorectal adenoma recurrence in the wheat bran fiber trial. Cancer Epidemiology, Biomarkers & Prevention. 2002;11: 906-914. References

100. Do you have any questions?