Understanding Nutrition and the Understanding Nutrition and the Consequences of UndernutritionConsequences of Undernutrition

Brian R. Barthel, Ph.D.Brian R. Barthel, Ph.D.

Components of NutritionComponents of Nutrition

We need to eat and drink to obtain:We need to eat and drink to obtain: Nutrients:Nutrients: chemical compounds in foods to chemical compounds in foods to

provide fuel for energy (measured in provide fuel for energy (measured in kilocalories), growth, maintenance and to kilocalories), growth, maintenance and to regulate body processesregulate body processes• Six classes: carbohydrates, fats, protein, vitamins, Six classes: carbohydrates, fats, protein, vitamins,

minerals, waterminerals, water Phytochemicals:Phytochemicals: nonnutrient compounds nonnutrient compounds

that contribute to health and may play a role that contribute to health and may play a role in fighting chronic diseasesin fighting chronic diseases

What Is Nutrition and Why Is What Is Nutrition and Why Is Good Nutrition So Important?Good Nutrition So Important?

Nutrition:Nutrition: a science that studies how a science that studies how nutrients and compounds in foods nourish nutrients and compounds in foods nourish and affect body functions and healthand affect body functions and health Chronic deficiencies, excesses, and imbalances Chronic deficiencies, excesses, and imbalances

of nutrients can affect health, both short-term of nutrients can affect health, both short-term and long-term.and long-term.

Good nutrition plays a role in reducing the risk of Good nutrition plays a role in reducing the risk of many chronic diseases and conditions, including many chronic diseases and conditions, including heart disease, cancer, stroke, diabetes, heart disease, cancer, stroke, diabetes, osteoporosis, high blood pressure, and obesity.osteoporosis, high blood pressure, and obesity.

What Are the Essential Nutrients and What Are the Essential Nutrients and Why Do You Need Them?Why Do You Need Them?

The six classesThe six classes of nutrients are all essential in of nutrients are all essential in the diet.the diet. Alcohol provides calories but is not an essential Alcohol provides calories but is not an essential

nutrient.nutrient. Macronutrients:Macronutrients: energy-yielding nutrients energy-yielding nutrients

needed in higher amountsneeded in higher amounts Carbohydrates, lipids (fats) and proteinsCarbohydrates, lipids (fats) and proteins

Micronutrients:Micronutrients: needed in smaller amounts needed in smaller amounts Vitamins and mineralsVitamins and minerals

Water:Water: Large amounts of water needed daily Large amounts of water needed daily

What Are the Essential Nutrients and What Are the Essential Nutrients and Why Do You Need Them?Why Do You Need Them?

Carbohydrates:Carbohydrates: supply supply glucoseglucose, a major energy , a major energy source. source.

Fats:Fats: are another major fuel source and also: are another major fuel source and also: Cushion organsCushion organs Insulate body to maintain body temperatureInsulate body to maintain body temperature

Proteins:Proteins: can provide energy but better suited for: can provide energy but better suited for: Composed of Amino AcidsComposed of Amino Acids Growth and maintenance of muscle, tissues, organsGrowth and maintenance of muscle, tissues, organs Making hormones, enzymes, healthy immune Making hormones, enzymes, healthy immune

system system Transporting other nutrientsTransporting other nutrients

What Are the Essential Nutrients andWhat Are the Essential Nutrients and Why Do You Need Them? Why Do You Need Them?

Vitamins and MineralsVitamins and Minerals are are essential for metabolismessential for metabolism.. Many assist Many assist enzymesenzymes in in

facilitating chemical facilitating chemical reactions in the bodyreactions in the body• ExampleExample: B vitamins are : B vitamins are

coenzymescoenzymes in carbohydrate in carbohydrate and fat metabolism.and fat metabolism.

Minerals:Minerals: Key role in body Key role in body processes and structuresprocesses and structures

What Are the Essential Nutrients and What Are the Essential Nutrients and Why Do You Need Them…Cont.?Why Do You Need Them…Cont.?

Water:Water: is vital for many processes in your body. is vital for many processes in your body. Part of fluid medium inside and outside of cellsPart of fluid medium inside and outside of cells Helps chemical reactions, such as those Helps chemical reactions, such as those

involved in energy productioninvolved in energy production Key role in transporting nutrients and oxygen to Key role in transporting nutrients and oxygen to

cells and removing waste productscells and removing waste products Lubricant for joints, eyes, mouth, intestinal tractLubricant for joints, eyes, mouth, intestinal tract Protective cushion for organsProtective cushion for organs

How Should You Get These Important Nutrients?How Should You Get These Important Nutrients?

The best way to meet your daily nutrient The best way to meet your daily nutrient needs is with a well-balanced diet.needs is with a well-balanced diet. Composed of a Composed of a varietyvariety of foods, providing: of foods, providing:

• Essential nutrients from all six classesEssential nutrients from all six classes• Fiber and phytochemicalsFiber and phytochemicals

Whole grains, fruits and vegetables are Whole grains, fruits and vegetables are rich sources.rich sources.

What Is Healthy Eating and What Is Healthy Eating and What Tools Can Help?What Tools Can Help?

Key principles of healthy eating:Key principles of healthy eating: BalanceBalance VarietyVariety ModerationModeration

Undernutrition:Undernutrition: state of inadequate nutrition state of inadequate nutrition Overnutrition:Overnutrition: excess nutrients and/or excess nutrients and/or

calories in dietcalories in diet Malnourished:Malnourished: long-term outcome of long-term outcome of

consuming diet that doesn’t meet nutrient consuming diet that doesn’t meet nutrient needsneeds Can result from both under- and overnutritionCan result from both under- and overnutrition

Obesity in AmericaObesity in America

Leading Causes of Death in the United States

Leading Causes of Death - PeruLeading Causes of Death - PeruTABLE 1. Leading causes of mortality, Peru, 2004.Causes of mortality (PAHO List 6/67) per 100,000 population1 Acute respiratory infections 68.02 Ischemic heart diseases 25.73 Cerebrovascular diseases 24.34 Septicemia, except for neonatal 21.55 Cirrhosis and certain other chronic liver diseases 21.46 Hypertensive diseases 16.97 Malignant stomach tumors 15.68 Respiratory disorders originating in the perinatal period 14.79 Tuberculosis 13.210 Diabetes mellitus 12.3Source: Adapted from Peru, Ministerio de Salud, mortality database.

Causes of Death Southern Highlands, Peru

Leading causes of death, Southern Highlands, Peru, 2000.Causes of mortality (List 6/67 PAHO) per 100,000 population1 Acute respiratory infections 147.92 Cirrhosis and certain other chronic liver diseases 51.03 Cardiac insufficiency 46.5

4 Nutritional deficiencies and anemia 44.85 Appendicitis, hernia of the abdominal cavity, and intestinal obstruction 44.26 Cerebrovascular diseases 41.37 Respiratory disorders originating during the perinatal period 31.38 Septicemia, except for neonatal 26.29 Land transportation accidents 25.910 Malignant stomach tumors 25.0Source: Adapted from Peru, Ministerio de Salud, mortality database.

Nutritional Profile of PeruNutritional Profile of Peru

Nationwide, 24 percent of children under five are chronically undernourished, and the prevalence has not changed over the last decade. In remote rural areas, rates can reach up to 70 percent (ENDES 2004). Almost 50 percent of children less than five suffer from anaemia, and the figures are much higher in the highlands (60-70 percent).

Issues Contributing to Undernutrition in PeruIssues Contributing to Undernutrition in Peru

Approximately 53 percent of the Peruvian population lives Approximately 53 percent of the Peruvian population lives below the national poverty line, and 25 percent lives in below the national poverty line, and 25 percent lives in extreme poverty. Peru ranks 82nd out of 177 countries (2006 extreme poverty. Peru ranks 82nd out of 177 countries (2006 HDI). HDI).

Insufficient allocation of public resources in the areas of Insufficient allocation of public resources in the areas of health, education and infrastructure, as well as limited health, education and infrastructure, as well as limited availability of farming land and very low yields of agricultural availability of farming land and very low yields of agricultural production in areas higher than 3,000 meters above sea level production in areas higher than 3,000 meters above sea level make the Southern Andean population extremely vulnerable make the Southern Andean population extremely vulnerable to food insecurity. Forty two percent of the population cannot to food insecurity. Forty two percent of the population cannot cover the minimum required caloric intake (2,100 Kcal). cover the minimum required caloric intake (2,100 Kcal).

World Food Program

Climate and Natural Disaster IssuesClimate and Natural Disaster Issues

A lack of access to food commodities, poor consumption patterns, inadequate child care and nutrition practices and poor educational levels among mothers, are the main causes of chronic undernutrition in Peru.

Food insecurity in Peru tends to be periodically aggravated by recurrent emergencies which mainly affect the southern highland area. 2007 was a particularly difficult year in terms of natural disasters: floods, frost, hail storms and heavy snowfalls affected approximately 700.000 people in 13 Peru regions. And along with all the other disasters a 7.9 earthquake!

The Malnutrition Downward SpiralThe Malnutrition Downward Spiral

Essential and Nonessential Amino AcidsEssential and Nonessential Amino Acids

Nine essential amino acidsNine essential amino acids Cannot be made by the body Cannot be made by the body It is “essential” to obtain them from the diet.It is “essential” to obtain them from the diet.

Eleven nonessential amino acidsEleven nonessential amino acids Can be synthesized in the body from other Can be synthesized in the body from other

amino acids or by adding nitrogen to carbon-amino acids or by adding nitrogen to carbon-containing structurescontaining structures

Conditionally essential amino acidsConditionally essential amino acids Under certain conditions, some nonessential Under certain conditions, some nonessential

amino acids cannot be made in body.amino acids cannot be made in body.

How Much Protein Do You Need and How Much Protein Do You Need and What Are Protein-Rich Food Sources?What Are Protein-Rich Food Sources?

Protein quality varies among food sourcesProtein quality varies among food sources.. Depends on digestibility and amino acid profileDepends on digestibility and amino acid profile

Complete proteins contain all of the essential Complete proteins contain all of the essential amino acids along with the nonessential ones.amino acids along with the nonessential ones.

• Examples: animal proteins, soy proteinExamples: animal proteins, soy protein Incomplete proteins are low in one or more Incomplete proteins are low in one or more

essential amino acidsessential amino acids (the limiting amino acid). (the limiting amino acid).• Example: plant proteinsExample: plant proteins

What Happens if You Eat Too Little Protein?What Happens if You Eat Too Little Protein?

Eating too little protein:Eating too little protein: Low-protein diets associated with loss of bone Low-protein diets associated with loss of bone

massmass Protein Energy Malnutrition (PEM)Protein Energy Malnutrition (PEM)

Inadequate calories and/or proteinInadequate calories and/or protein More common in children, because they are More common in children, because they are

growinggrowing Factors: poverty, poor food quality, insufficient Factors: poverty, poor food quality, insufficient

food, unsanitary living conditions, lack of food, unsanitary living conditions, lack of knowledge, stopping lactation (nursing) too earlyknowledge, stopping lactation (nursing) too early

Protein Energy MalnutritionProtein Energy Malnutrition Kwashiorkor:Kwashiorkor: severe deficiency of dietary protein severe deficiency of dietary protein

Signs:Signs: edema, muscle loss, skin rashes, hair edema, muscle loss, skin rashes, hair changes, water and electrolyte imbalanceschanges, water and electrolyte imbalances

Seen in children weaned to low-protein cerealsSeen in children weaned to low-protein cereals Marasmus:Marasmus: severe deficiency of caloriessevere deficiency of calories

Signs: emaciation, lack of growth, loss of fat Signs: emaciation, lack of growth, loss of fat storesstores

Marasmic Kwashiorkor:Marasmic Kwashiorkor: worst of both conditionsworst of both conditions Medical treatment and food:Medical treatment and food: Two-step approach Two-step approach

Comparison of Kwashiorkor and MarasmusComparison of Kwashiorkor and Marasmus

A classic sign of Kwashiorkor is edema.

Marasmus results in an emaciated appearance.

Signs of Protein Energy MalnutritionSigns of Protein Energy Malnutrition in Peruvian Children in Peruvian Children

Treatment of Protein Energy MalnutritionTreatment of Protein Energy Malnutrition Step One Step One In both children and adults, the treatment of protein-In both children and adults, the treatment of protein-

energy malnutrition (PEM) is to correct fluid and electrolyte energy malnutrition (PEM) is to correct fluid and electrolyte abnormalities and to treat any infections. The most common abnormalities and to treat any infections. The most common electrolyte abnormalities are hypokalemia, hypocalcemia, electrolyte abnormalities are hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia. Macronutrient hypophosphatemia, and hypomagnesemia. Macronutrient repletion should be commenced within 48 hours under the repletion should be commenced within 48 hours under the supervision of nutrition specialists.supervision of nutrition specialists.

Step two: Step two: The second step in the treatment of protein-energy The second step in the treatment of protein-energy malnutrition (which may be delayed 24-48 h in children) is to malnutrition (which may be delayed 24-48 h in children) is to supply macronutrients by dietary therapy. Milk-based formulas supply macronutrients by dietary therapy. Milk-based formulas are often the treatment of choice for young children.are often the treatment of choice for young children.

CorrectCorrect contributors to the PEM condition in the first place contributors to the PEM condition in the first place

Vitamin AVitamin A

Vitamin A:Vitamin A: retinoids (retinol, retinal, retinoic retinoids (retinol, retinal, retinoic acid)acid) Preformed vitamin APreformed vitamin A only found in animal only found in animal

foods: liver, eggs, fortified milk, cheesefoods: liver, eggs, fortified milk, cheese Some plants contain Some plants contain PProvitamin Arovitamin A carotenoids, carotenoids,

which are converted to retinol in your body.which are converted to retinol in your body.• Carotenoids, including beta-carotene, are pigments Carotenoids, including beta-carotene, are pigments

which give color to carrots, cantaloupe, sweet which give color to carrots, cantaloupe, sweet potatoes, spinach, broccoli.potatoes, spinach, broccoli. Like fat-soluble vitamins, absorbed more efficiently if fat Like fat-soluble vitamins, absorbed more efficiently if fat

present in intestinal tractpresent in intestinal tract

Vitamin AVitamin A

Functions:Functions: Essential for healthy eyesEssential for healthy eyes

• Component of rhodopsin and iodopsin, light-sensitive Component of rhodopsin and iodopsin, light-sensitive proteins needed for visionproteins needed for vision

Involved in cell differentiation, reproduction and Involved in cell differentiation, reproduction and immunity by promoting gene expression for:immunity by promoting gene expression for:

Healthy skin, mucus membranesHealthy skin, mucus membranes Bone growthBone growth Fetal developmentFetal development White blood cells to fight deadly infectionsWhite blood cells to fight deadly infections

Animation: Vitamin A and Epithelial TissueAnimation: Vitamin A and Epithelial Tissue

| Vitamin A and Epithelial Tissue

Vitamin AVitamin AToo little:Too little:

Prolonged vitamin A deficiency leads to Prolonged vitamin A deficiency leads to xerophthalmiaxerophthalmia.. Abnormal dryness of the conjunctiva and cornea of the Abnormal dryness of the conjunctiva and cornea of the

eyes due to a systemic deficiency of vitamin A eyes due to a systemic deficiency of vitamin A • #1 cause of preventable blindness in children, mostly in #1 cause of preventable blindness in children, mostly in

developing countriesdeveloping countries As many as 500,000 children go blind each year due to As many as 500,000 children go blind each year due to

vitamin A deficiency. vitamin A deficiency.

Chronic vitamin A deficiency causes night Chronic vitamin A deficiency causes night blindness.blindness. Vitamin A deficiency also associated with stunting of Vitamin A deficiency also associated with stunting of

bonesbones

Vitamin DVitamin DCalled “Sunshine Vitamin” because vitamin D Called “Sunshine Vitamin” because vitamin D

is made in the body with help of sunlight is made in the body with help of sunlight (UV)(UV) Cholesterol-containing compound in skin is Cholesterol-containing compound in skin is

converted to inactive form of vitamin Dconverted to inactive form of vitamin D People with insufficient sunlight exposure must People with insufficient sunlight exposure must

meet needs through diet; vitamin D in foods is meet needs through diet; vitamin D in foods is also an inactive form.also an inactive form.

Inactive form converted to circulating form in Inactive form converted to circulating form in liver, to active form in kidneysliver, to active form in kidneys

Vitamin DVitamin DFunctions: active form acts as a hormoneFunctions: active form acts as a hormone

Regulates two important bone minerals: calcium Regulates two important bone minerals: calcium (Ca) and phosphorus (P)(Ca) and phosphorus (P)• Stimulates intestinal absorption of Ca and P to Stimulates intestinal absorption of Ca and P to

maintain healthy blood levels and build and maintain maintain healthy blood levels and build and maintain bones bones

• When dietary calcium is inadequate, Vitamin D and When dietary calcium is inadequate, Vitamin D and parathyroid hormone cause calcium to leave bones to parathyroid hormone cause calcium to leave bones to maintain necessary blood levels.maintain necessary blood levels.

May prevent type 2 diabetes and some cancersMay prevent type 2 diabetes and some cancers

Vitamin DVitamin DToo much or too little:Too much or too little:

Overuse of supplements may lead to Overuse of supplements may lead to hypervitaminosis D,hypervitaminosis D, which causes which causes hypercalcemia.hypercalcemia.• Damaging calcium deposited in kidneys, lungs, blood vessels, heartDamaging calcium deposited in kidneys, lungs, blood vessels, heart• UL: 2,000 IU (50 UL: 2,000 IU (50 µµg)g)

Rickets:Rickets: vitamin D deficiency disease in children vitamin D deficiency disease in children• On the rise in U.S. due to decreased milk consumption, other factorsOn the rise in U.S. due to decreased milk consumption, other factors• The bones of children with rickets aren’t adequately mineralized with The bones of children with rickets aren’t adequately mineralized with

calcium and phosphorus, causing them to weaken and leading to calcium and phosphorus, causing them to weaken and leading to bowed legs.bowed legs.

Osteomalacia:Osteomalacia: adult equivalent of rickets adult equivalent of rickets

RicketsRickets

Before Treatment

After Treatment Wind Swept Rickets

Rickets Before and After TreatmentRickets Before and After Treatment

Childhood Rickets – Vitamin D DeficiencyChildhood Rickets – Vitamin D Deficiency

CalciumCalciumMost abundant mineral in body Most abundant mineral in body

>99% located in bones and teeth>99% located in bones and teeth

Functions:Functions: Helps build strong bones and teethHelps build strong bones and teeth Plays a role in muscles, nerves and bloodPlays a role in muscles, nerves and blood May help lower high blood pressureMay help lower high blood pressure May fight colon cancerMay fight colon cancer May reduce risk of kidney stoneMay reduce risk of kidney stone May reduce risk of obesity May reduce risk of obesity

CalciumCalciumDaily needs:Daily needs:

1,000-1,200 1,000-1,200 µg/dayµg/day, depending on age , depending on age

Food sources:Food sources: Milk, yogurt, cheese, dark green vegetables, Milk, yogurt, cheese, dark green vegetables,

kale, fish (with bones), calcium-fortified foods kale, fish (with bones), calcium-fortified foods like juices and cerealslike juices and cereals

CalciumCalcium

Too much or too little:Too much or too little: UL: 2,500 UL: 2,500 µg/dayµg/day Too much calcium leads to Too much calcium leads to hypercalcemia: hypercalcemia:

impaired kidneys, calcium deposits in bodyimpaired kidneys, calcium deposits in body Too little can lead to less dense, weakened, Too little can lead to less dense, weakened,

brittle bones and increased risk for brittle bones and increased risk for osteoporosisosteoporosis

IronIronFunctions:Functions:

Hemoglobin in red blood cells transports oxygen from lungs Hemoglobin in red blood cells transports oxygen from lungs to tissues and picks up carbon dioxide waste from cells.to tissues and picks up carbon dioxide waste from cells.

Myoglobin transports and stores oxygen in muscle cells.Myoglobin transports and stores oxygen in muscle cells. Helps enzymes that make neurotransmittersHelps enzymes that make neurotransmitters

Daily needs:Daily needs:

varies depending on gender and agevaries depending on gender and age Women 19-50: 18 mWomen 19-50: 18 mg/dayg/day : higher due to iron lost during : higher due to iron lost during

menstruation menstruation Males 11mg/day until age 18 then 8 mg/day afterMales 11mg/day until age 18 then 8 mg/day after

Food sources: Food sources: Dark green vegetables, beans; heme-iron in meats, liver, Dark green vegetables, beans; heme-iron in meats, liver,

fish and poultryfish and poultry

IronIronToo much or too little:Too much or too little:

Deficiency is most common nutritional disorder in worldDeficiency is most common nutritional disorder in world Iron-deficiency anemia occurs when iron stores depleted Iron-deficiency anemia occurs when iron stores depleted

and hemoglobin levels decreaseand hemoglobin levels decrease

IodineIodine Functions: needed by thyroid to make Functions: needed by thyroid to make

essential hormonesessential hormones Thyroid hormones regulate metabolic rate; help Thyroid hormones regulate metabolic rate; help

heart, nerves, muscle and intestines function heart, nerves, muscle and intestines function properlyproperly

Daily needs: adults: 150 Daily needs: adults: 150 µg/dayµg/day Food sources: iodized salt (400 Food sources: iodized salt (400 µg/tsp)µg/tsp)

Amount in foods is low, depends on iodine Amount in foods is low, depends on iodine content of soil, water, fertilizer content of soil, water, fertilizer

Salt-water fish have higher amounts.Salt-water fish have higher amounts.

IodineIodine Early sign of deficiency = Early sign of deficiency = goitergoiter (enlarged (enlarged

thyroid gland)thyroid gland) Not nearly as much a problem in Peru as it once Not nearly as much a problem in Peru as it once

waswas• Mandatory iodization of salt has decreased iodine Mandatory iodization of salt has decreased iodine

deficiency in U.S. but not in other parts of worlddeficiency in U.S. but not in other parts of world• Iodine deficiency during early stages of fetal Iodine deficiency during early stages of fetal

development can cause development can cause cretinismcretinism (congenital (congenital hypothyroidism).hypothyroidism).

Iodine DeficiencyIodine Deficiency

Goiter is an early sign of iodine deficiency

Cretinism can result from an iodine deficiency during the early stages of fetal development

Confronting UndernutrtionConfronting Undernutrtion

Prevent it in the first place through the Prevent it in the first place through the consumption of a variety of foodsconsumption of a variety of foods

Early identification of, and interaction with, Early identification of, and interaction with, those among us who may not be receiving those among us who may not be receiving adequate nutritionadequate nutrition

Begin and maintain treatment for PEM, and Begin and maintain treatment for PEM, and establishing an adequate food source for establishing an adequate food source for populations suffering from undernutritionpopulations suffering from undernutrition

Peruvian Native Foods Peruvian Native Foods Eat a Variety of TheseEat a Variety of These

Camote – high in caroteneCamote – high in carotene hoja de ollucohoja de olluco ZanahoriaZanahoria (carrot) (carrot) CochayuaoCochayuao (alga) (alga) cebadacebada (barley) (barley) trigotrigo (wheat) (wheat) Maize (corn)Maize (corn) QuinoaQuinoa Arvela secaArvela seca (dried peas) - (dried peas) -

ProtienProtien HuevoHuevo (egg) –Protein (egg) –Protein Pescado saladoPescado salado (dried fish, (dried fish,

caballa)caballa)

Carne de gallinaCarne de gallina (hen) (hen) Aceite, seb de carnero, Aceite, seb de carnero,

Linasa – FatsLinasa – Fats naranjanaranja (oranges) (oranges) MangosMangos Banana – not a source of Vit. Banana – not a source of Vit.

AA ChiclayoChiclayo (like a squash) (like a squash) aji secoaji seco (like chili) & (like chili) &

aderezosaderezos (sauce) (sauce) caldo verdecaldo verde

Thank You!Thank You!

Eat Healthy!Eat Healthy!