Dasar-dasar Gizi Masyarakat

Bahan ajar Semester 1 Modul 4 LBM 1 Prioritas Masalah Kesehatan   


Dasar-dasar gizi masyarakat
dr, Joko Wahyu Wibowo, M.Kes
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Keywords :
Dasar-dasar gizi masyarakat Dr. joko wahyu wibowo MKes Keadaan tubuh sebagai akibat dari keseimbangan antara konsumsi dan pemanfaatan zat gizi.  Normal   vs malnutrition.
Nutritional Status: (status gizi=keadaan gizi)
Community nutritional assessment To map out the magnitude and geographical distribution of malnutrition  Discover and analyze the ecological factors that directly or indirectly responsible  Suggest appropriate corrective measures
Preliminary step for further action
Malnutrition
A pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients. • Overnutrition • Undernutrition • Specific deficiency • Imbalance
Overnutrition
resulting from the consumption of an excessive quantity of food,   over an extended period of time
Undernutrition resulting from the consumption of an inadequate quantity of food,   over an extended period of time
Penyebab Gizi Kurang
Kurang Gizi
Pangan tak cukup
Pola asuh tak memadai
Yan Kes. dan sanitasi Tak memadai
Asupan gizi Infeksi
Pendidikan, Pengetahuan dan ketrampilan rendah
Pemberdayaan SDM kurang
Situasi Pol EK Sos
Pengangguran, Inflasi, kurang pangan dan kemiskinan
Akar masalah
Masalah di masyarakat
Penyebab tak langsung
Penyebab langsung
Epigenetic Inheritance  Genetic tags are passed down through generations  When the zygote is formed many epigenetic tags are removed from the chromosomes of the parents, but some remain 
Epigenetic Inheritance cont.
 Previously believed that genetic information was passed through DNA only  Studies in the field of epigenetics shows that parent’s experiences are passed on to offspring through epigenetic tags
Environment &Epigenome
Mounting evidence suggests that fetuses are surprisingly susceptible to outside influences such as environmental pollutants, pesticides, and other toxins.
Agouti “Twin” Sisters
Coat color serves as a sensor for the degree of methylation present


Contrasting phenotypes
deletion normal dosage
duplication
duplication
Nutrigenomics Definition
 Analyzing the effects of diet on the activity of on individual’s genes and health and the effect of an individuals genes on metabolism of dietary chemicals  Diet = nutritional science Activity of genes = molecular biology Individual = genetics/genomics Health = physiology  A systems biology science : Multi - disciplinary
Nutrient is independent variable
Gene expression is independent variable
Gene ExpressionNutrient
12/2/2015 17
What is Nutrigenomics?
 Nutrigenomics is the science that examines the response of individuals to food compounds using post-genomic and related technologies.  The long-term aim of nutrigenomics is to understand how the whole body responds to real foods using an integrated approach.  Studies using this approach can examine people (i.e. populations, sub-populations based on genes or disease - and individuals), food, life-stage and life-style without preconceived ideas. 
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Genes – Lifestyle – Calories
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Nutrigenomics
Target Genes Mechanisms Pathways
Signatures Profiles Biomarkers
Foods Nutrition
Molecular Nutrition & Genomics
Nutritional Systems Biology
•Identification of dietary signals •Identification of dietary sensors •Identification of target genes •Reconstruction of signaling pathways
•Measurement of stress signatures •Identification of early biomarkers
Small research groups Small budgets
Large research consortia Big money
Complexity
12/2/2015 20 Molecular nutrition
12/2/2015 21
Energy homeostasis
Nutrient absorption
Cell proliferation
Nutritional factors
Transcription factors
Gene transcription
Nutrients acts as dietary signals
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Transcription-factor pathways mediating nutrient-gene interaction
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Intestine Liver, Muscle Blood Adipose tissue
Nutrients Signaling Cells Animal Humans OrgansFunctionsProteinsGenes Healthy Food
Lipids Fatty acids Sugars Calcium
Transporters Transcription factors Enterocytes Hepatocytes Adipocytes Lymphocytes
Target genes of nutrients
Mouse Models
Intervention Studies
Proteins Posttranslational Regulation
Metabolic Implications Metabolites
Signaling Cells Animal Humans OrgansFunctionsProteinsGenes
Nutrient-related cellular sensing + Metabolic stress
Diet-related organ sensing, Sensitivity genes + Molecular Phenotype
Gene expression Signatures
Gene regulation by nutrients
Prevention of Metabolic Syndrome
Dietary Programming
Metabolomics Systems Biology
Molecular Biology Tools
Early Molecular Biomarkers
Transcriptome Proteome
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Two Strategies (1)The traditional hypothesis-driven approach: specific genes and proteins, the expression of which is influenced by nutrients, are identified using genomics tools — such as transcriptomics, proteomics and metabolomics — which subsequently allows the regulatory pathways through which diet influences homeostasis to be identified . Transgenic mouse models and cellular models are essential tools .
provide us with detailed molecular data on the interaction     between  nutrition and the genome . (2) The SYSTEMS BIOLOGY approach: gene, protein and metabolite signatures that are associated with specific nutrients, or nutritional regimes, are catalogued, and might provide ‘early warning’molecular biomarkers for nutrient-induced changes to homeostasis.
Be more important for human nutrition, given the difficulty of    collecting tissue samples from ‘healthy’ individuals.
12/2/2015 25 Science (1999) 285:1390-1393
Caloric restriction–induced alterations in gene expression
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Conclusion of gene expression profile of aging and its retardation by caloric restriction
Science (1999) 285:1390
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Decreased glucose tolerance
Muscle insulin resistence
b Cell compensation
Increased gluconeogenesis in liver
Increased lipolysis in visceral fat
b Cell decompensation
Genes Ageing
Obesity hyperinsulemia
Increased fatty acids levels
Increased glucose output
Decreased insulin secretion
Diabetes
Metabolic Syndrome and Diabetes
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Signatures of health & stress -The “two hits”:  Metabolic and pro-inflammatory stress
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Strategies we need in gene-nutrient interactions
 Effects of individual genetic variation in response to nutrient Nutrigenetics Definition  Any two individuals share 99% of their DNA sequence  Most common form of variation
 Single nucleotide polymorphism (SNP)  Changes in single base pair  Occur ~ 1 in every 1000bp of human genome (~ 3 million in human genome)  SNPs may alter regulation of gene expression, mRNA processing (splicing, half-life etc) and protein activities
Micronutrients that act directly or indirectly as antioxidants or influence DNA expression
Vitamin A
Vitamin E
Folic acid
Vitamin D
Zn,Se,Fe Mg, Cu
Vitamin B2
Vitamin B3
Vitamin B6
Vitamin C
Vitamin B12
Nuclear DNA Damage
Threat and management of deleterious radicals generated by cellular respiration
Free radicals +O2
Mitochhondria l DNA Damage
Superoxide dismutase
Catalase
H2O2
H2Oand O2
O2 + Glucose
Membrane Damage
Antioxidants evolutions & Human Health
Nutrigenomics (Nurture)
 Nutrigenomics ◦ Nutrition + genomics ◦ How do nutrients alter gene expression?
Essential and nonessential nutrients
Transcription Factor Nucleus
DNA Target
Gene
Change mRNA
Protein (< or >)
Biological responses in cell process(es)
Do nutrients affect gene expression? ◦ Vitamin E regulates protein kinase C activity in smooth muscle cells (Azzi 1991) ◦ Modulates the expression of the hepatic alpha-tocopherol transfer protein (Hosomi 1997) ◦ Tocopherol-dependent transcription factor (tocopherol associated protein, TAP) has been identified (Stocker 1999) ◦ CoQ10 in human muscle cells has shown effects on 12,000 genes (Linnane 2002) ◦ Vitamin D3 affects 20,000 genes in human prostate cancer cells (Krishnan 2003) ◦ EGb 761 alters mRNA levels of the GLUT3 in hippocampal neurons, increasing neuronal glucose supply in rats (Loffler 2001) ◦ L-leucine interacts with multiple genes via mTOR and Akt pathways

Iodine deficiency disorders
Kurang vitamin A
Defisiensi Folat
Nutritional assessment
 Indirect * dietary survey * assessment of ecological factors
 Direct * biochemical test * biophysical methods * nutritional anthropometry * clinical sign
Dietary survey
National level •Food balance   sheet • Market data base
Household level • Food account • List recall
Individual level •Single 24 hour recall •Multiple 24 hour recall •Food frequency •Food diary record •Weighed assessment
Gibson RS 1990. Principles of nutritional assessment
1. Biological determinants : sex, intra uterine environment,  birth  order,  birth weight, parental  size, genetic  constitution
2. Environmental : Nutrition, Climate, living  condition,socio-economic  condition, diseases, psychological factor etc
Human growth is influenced by
*Anthropometric Measurements = picture of human growth at different age  level (from fetoes to adulthood):
 height/length, weight  upper arm circumference (UAC/LILA)  head circumference  BMI (body Mass Index)  Skinfold thickness
 raw measurements do not mean  anything, if not compared to   REFERENCE or STANDARDS.
Body weight

Body length & height
Mid Upper Arm Circumference
Head circumference
Triceps Skin Fold
Knee height measurement
 A valid index of linear growth, can detect growth increments in children more readily and over a short time period in compared to height measurements.  Have a greater precision.  In infants: the growth is not linear, with a period of slow and then accelerated growth  In adults: highly correlated with stature & maybe used to estimate height in persons with severe spinal curvature or who are unable to stand. The available formula are for Caucasian and African-American. Population-specific equations maybe necessary.  Body Weight can also be calculated from an equation based on the values of calf circ, knee height, muac, Subscap skinfold (for a selected population living in US)


Arm Span
 Is also highly correlated with stature.  Especially useful for assessing retrospective measurement that is stature prior to any age associated loss in the elderly.  It is difficult to measure in non ambulatory persons and individuals with significant chest andspinal deformities.  A study showed that knee height is a more valid estimate of maximum stature during adulthood than arm span

Elbow breadth  Is a good measure of skeletal dimensions/ frame size  Highly associated with lean body mass and muscle size.

Interpretation and evalution of anthropometric data
 Anthropometric indices, not the raw measurements, are interpreted and evaluated  For chidren: WHZ (for wasting) & HAZ (for stunting) are the preferred anthropometric indices of body size.  Anthropometric indices can be used at individual and population levels for : assess nutritional status, screening & response during intervention  At population level can be also used to identify the determinants and consequences of malnutrition and for nutritional surveillance.
KMS
Selecting the appropriate indices 1:excellent, 4: poor
WHZ HAZ WAZ
Usefullness in populations where age is uncertain
1 4 4
Usefullness in identifying wasted children
1 4 3
Sensitivity to weight change over a sort period of time
1 4 2
Usefullness in identifying stunted children
4 1 2

Klasifikasi status gizi
Indeks Status Keterangan BB/U Gizi lebih Gizi baik Gizi kurang Gizi buruk >= 2 SD - 2 SD s/d +2 SD -2 SD s/d – 3 SD < - 3 SD TB/U Normal Pendek (stunted) -2 SD s/d + 2 SD < - 2SD
BB/TB Gemuk Normal Kurus (wasted) Sangat kurus
>= 2 SD -2 SD s/d + 2 SD < -2 SD s/d – 3 SD < - 3 SD
Interpretasi berdasar kombinasi indikator
Combination Interpretation BB/TB: N, BB/U: R, TB/U: R Normally fed, with past history of malnutrition
BB/TB: N, BB/U: N, TB/U: N Normal
BB/TB: N, BB/U: T, TB/U: T Tall, normally nourished
BB/TB: R, BB/U:R, TB/U: T Presently underfed ++
BB/TB: R, BB/U: R, TB/U: N Presently underfed +
BB/TB: R, BB/U: N, TB/U: T Presently underfed
BB/TB: T, BB/U: T, TB/U: R Obese ++
BB/TB: T, BB/U: N, TB/U: R Overfed with past history of malnutrition
BB/TB: T, BB/U: T, TB/U: N Overfed but not necessarily obese
The advantages of anthropometric assessment
•simple, safe, inexpensive, non invasive • unskilled personnel can perform measurement procedures • precise and accurate • may be used to evaluate changes in nutritional status over time   and from one  generation to the next • can assist in the identification of mild to moderate malnutrition, as well as severe states of malnutrition
Limitations of anthropometric assessment
Relatively insensitive, cannot detect disturbance in nutritional status over short periods of time or identify specific nutrients deficiencies
Unable to distinguish disturbances in growth or body composition induced by specific nutrient (e.g. Zinc) deficiencies from those caused by imbalances in protein and energy intake
Certain non-nutritional factors (disease, genetics, diurnal variation) can reduce the specificity and sensitivity
Sources of error in nutritional anthropometry
•Measurements error : examiner, instrument, object •Alteration in the composition and physical properties of certain tissues (tissue hydration, oedema, hepatomegaly) • Invalid assumptions : e.g. skin fold in fact the relationship between subcutaneous and internal fat is non linier
Anthropometric assessment of body composition
 Skinfold thickness measurements: ◦ Triceps skinfold ◦ Biceps skinfold ◦ Subscapular skinfold ◦ Suprailiac skinfold ◦ Midaxillary skinfold  Multiple skinfold measurements can be used for measuring percent body fat
Anthropometric assessment of body composition