Biomedical Sciences Sem 5

Selective:
Nutritional Epidemiology-
Introduction

Lecture by:
A/P Dr Tony Ng
IMU

1
Lesson Outcomes
At the end of this lesson the student should
be able to:
1. describe the purpose and components of epidemiology.
2. state the three disease descriptors in epidemiology.
3. describe nutritional epidemiology- What is it? How is it
important?
4. state the goals of nutritional epidemiology.
5. describe the advantages and disadvantages of
nutritional epidemiology.
6. explain the relationship between exposure, outcome
and confounder
7. state the limitations in nutritional epidemiology
research. 2
What is epidemiology?
Epidemiology is the study of
the distribution and determinants
of health-related states or events
(including disease frequency),

and the application of this study to the

control of diseases and other health
problems. 3
Purposes of Epidemiology
1. To investigate nature / extent of health-
related phenomena in the community/
identify priorities
2. To study natural history and prognosis
of health-related problems
3. To identify causes and risk factors
4. To recommend/ assist in application of/
evaluate best interventions (preventive
and therapeutic measures)
5. To provide foundation for public policy
Components of Epidemiology
Measure disease frequency
- Quantify disease
Assess distribution of disease
- Who is getting disease?
- Where is disease occurring?
- When is disease occurring?
Which lead to.

Formulation of hypotheses concerning
causal and preventive factors
Identify determinants of disease
- Hypotheses are tested using epidemiologic
studies
 Descriptive and Analytical
Epidemiology
1. Descriptive epidemiology
Describes the occurrence of disease (cross-
sectional)

2. Analytic epidemiology
Observational (cohort, case control, cross-
sectional, ecologic study) researcher
observes association between exposure and
disease, estimates and tests it
Experimental (RCT, quasi experiment)
researcher assigns intervention (treatment),
and estimates and tests its effect on health
outcome
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Basic Triad of Descriptive
Epidemiology
The three essential characteristics
(descriptors) of disease we look for
in descriptive epidemiology are:

PERSON
PLACE
TIME
Analytic epidemiology
Study design: cohorts & case control
& cross-sectional studies
Choice of a reference group
Biases
Impact Stratification
Causal inference - Effect modification
- Confounding
Matching
Multivariable analysis
Nutritional epidemiology

What is it?
How is it important?
(Reference: Nutrition Epidemiology
by Walter Willet)

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Nutritional epidemiology-
the study of the impact of nutritional
exposures on populations/
individuals and related health/
nutritional outcomes.

Most of nutritional epidemiology is

concerned with effects of diet on
chronic diseases that are multi-
factorial (multiple etiologies) and that
take years to develop (long latent period).
10
Nutritional epidemiology:

Concept:
diet influences occurrence of diseases

Nutr epidemiology is a relatively new

discipline:
the basic method used for > 200 years
to identify essential nutrients

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Nutritional
epidemiology

The field is often dated to 1753, when Dr

James Lind observed that fresh fruits and
vegetables could cure scurvy and
conducted one of the earliest clinical
trials with lemons and oranges, which, he
noted, had "most sudden and good
effects" in treating the disease. Much
later, it was found that vitamin C
deficiency was the cause. 12
Other milestones in
nutritional epidemiology

Kanehiro Takaki in 1884 links Japanese

sailors' diet of polished rice to the disease
beriberi. He adds milk and vegetables to their
diet and eliminates the disease.
Later Christiaan Eijkman, working in Batavia,
advanced his theory that beriberi was caused
by a nutritional deficiency. He later identified
as vitamin B1, earning him the 1929 Nobel
Prize in Physiology/Medicine. 13
 Nutritional Epidemiology will help us
to understand the relationship between diet
and long-term health and disease.
But we dont know enough of this
relationship- many of the major
questions about diet and disease
remain unresolved.
The complex nature of diet has posed an
unusually difficult challenge to nutritional
epidemiology.
Our understanding of biologic mechanisms
remains far too incomplete to predict
confidently the ultimate consequences of14
eating a particular food or nutrient.
We do know, however, the
epidemiologic studies directly
relating intake of dietary
components to risk of death or
disease among humans play a
critical complementary role to
laboratory investigation.
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Nutritional epidemiology.
The method can also be used to:
Describe the nutrition status of populations
or specific subgroups of a population.

Develop specific programs or services for

members of the group whose nutrition
status appears to be compromised.

Evaluate nutrition interventions.

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 Goals of nutritional
epidemiology
1.
The most basic goal is
monitoring the food
consumption, nutrient intake
and nutritional status of a
population.

17
 Goals of nutritional
epidemiology

2.
To generate new hypotheses
about diet and disease, to
produce evidence that supports
or refutes existing hypotheses
and to assess the strength of diet-
disease associations. 18
 Goals of nutritional
epidemiology
3.
The overall goal is to contribute
to the prevention of disease and
the improvement of public
health.

19
 Advantages of nutritional
epidemiology
1.
The key advantage is
its direct relevance to
human health.
Epidemiologists study real life. They do not
need to extrapolate from animal models or in
vitro systems. The results of their work are often
used to calculate direct estimates of risk, which
can then be translated into specific
recommendations for changes in nutrient
intakes or food consumption patterns. 20
Advantages of nutritional
epidemiology
2.
Findings from nutritional
epidemiology can even have direct
implications for food processing
and technology.

21
 Industrially produced
trans fats

Clear Solid or
vegetable oils semi-solid fats

by hydrogenation Source: Alan Maryon-Davis

 *Estimated changes in CHD risk when CHO is
substituted by a specified dietary component
Nurses Health Study:
80,082 nurses followed-up
S fats 14 years [Hu et al. (1997)
N
100 93 TRA or your NEJM, 337:1491-1499]
f
bad t;
80 hear e than TRANS fats
w ors ! also increase
s
60 SF A
risk of type 2
% Change in

40 diabetes!
CHD risk

17 Overall:
20 TFAs 2 to
2
0 10 times
worse than
TRANS SFAs MONO PUFA Total the C12-16
-20
2% 5% -19 Fat SFAs when
-40 kcal kcal 5% 5% impact on
kcal -38
kcal other risk
-60 5%
factors
kcal
considered!
For eg., recent epidemiological studies
found that high intakes of trans fatty
acids (found in margarine/ hardened or
processed vegetable fats) is associated
with an increased risk of coronary
heart disease
Margarine manufacturers sought
alternative ways to reformulate their
products to reduce their trans fatty acid
content.

(Re: Inter-esterification
of fats to replace
commercial
hydrogenation) 24
 Disadvantages of Nutritional
Epidemiology
1.
The most important one is the potential for
many kinds of bias.

Bias is defined as systematic error,

resulting in over- or underestimation of the
strength of an association between an
exposure and an outcome.

Studies in nutritional epidemiology must be

designed and executed with great care to
minimise bias. 25
 Disadvantages of Nutritional
Epidemiology
2.
The difficulty in determining whether
observed associations are causal. If the
association between a factor and a disease is
not causal, efforts to modify exposure to that
factor will not reduce disease risk.

For eg., even though the drinking of alcohol is associated with

lung cancer risk, efforts to discourage alcohol consumption would
not be likely to reduce the lung cancer death rate, because the
relationship is not causal. Instead, it reflects the association of both
alcohol intake and lung cancer with a third factor cigarette
smoking. 26
 Disadvantages of Nutritional
Epidemiology
3.
Preliminary or unconfirmed epidemiological
findings encourage the misuse and over-
interpretation of data. This is especially true
when come to the attention of the news media
and the general public.
For example, the reports of an association between
margarine intake and cardiovascular disease may
have prompted some consumers to switch back to
butter, even though most experts believe that this
course of action would not be beneficial to
cardiovascular health.
27
Nutrition problems in the past:
Typical deficiency syndromes
Protein energy malnutrition
Iron deficiency anemia
Goitre
High frequency among those with very low
intake
Short latent periods
Can be reversed within days or weeks
28
Contemporary nutritional
epidemiology:
Major diseases of Western civilization
Heart disease
Cancer
Osteoporosis
Cataracts
Stroke
Diabetes
Congenital malformations
Chronic nature of onset 29
Why is it hard to study contemporary
nutrition-related disease?
Characteristics
1. Multiple causes
- diet, genetic, occupational, psychosocial, and infectious
factors; levels of physical activity; behavioral characteristics

2. Long latent periods

- cumulative exposure over many years, or relatively short
exposure occurring many years before diagnosis

3. Occur with relatively low frequency

- despite a substantial cumulative lifetime risk

4. Conditions not readily reversible

5. May result from excessive and / or insufficient
intake of dietary factors 30
For example, coronary heart disease has a
wide variety of recognised risk factors including
age, gender, menopausal status in women,
family history, body weight, blood pressure,
blood cholesterol and diabetes.

Other factors, such as the degree of oxidation

of blood lipoproteins and levels of the amino
acid metabolite homocysteine, may also be
involved. Many of these risk factors and
suspected risk factors are influenced by
multiple aspects of diet.

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For example,
Intakes of several types of fatty acids influence blood
cholesterol levels and
Intakes of three different B vitamins influence
homocysteine levels.

Some risk factors exert their effects over long periods of

time (usually by influencing the progression of
atherosclerosis).
Others, however, may exert their effects very quickly (by
influencing the likelihood of blood clotting).

The more that scientists learn about the nature of

coronary heart disease, the more complex the causes
seem to be. 32
So, scientists do not fully
understand the reasons for
differences in coronary
heart disease rates at
different times and places.

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The methods used in nutritional
epidemiology focus on measuring
the exposure to nutritional factors, the
frequency and distribution of disease, and the
exposure to other factors that could confound the
hypothesized association.

Nutritional exposures are defined

or measured through the intake of foods, nutrients,
and non-nutrients, additives, contaminants, and
chemicals in foods that are incorporated into a food
as part of the agricultural process or were formed
during food processing or preparation.
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Outcomes
Outcomes may be:
a disease state;
anthropometric measures;
physiological measures (eg. blood pressure, serum
cholesterol);
biological markers; or
they may be expressed relative to some standard such as,
for example, a dietary reference value.
Often the term diet-disease relationship is used to
describe exposure-outcome relationship, even when
disease is not the outcome of interest. The
development of a specific and clearly defined
research question leads to a clear understanding of
exactly which exposures and outcomes are of
35
interest.
Exposure, Outcome, Confounding

Consider the following questions as example:

Does alcohol intake increase the risk of lung

cancer?

Alcohol lung cancer

(exposure) (outcome)

In this relationship, we assume that one event

(exposure) affects the other (outcome).
36
 Confounding
The relationship between exposure and outcome may
be mixed up with the effect of another exposure (3rd
variable) on the same outcome, the two exposures
being correlated.
This phenomenon is known as confounding.

Alcohol Lung cancer

(exposure) (outcome)

Smoking
(confounder)

Distortion of measure of Confounding should be

effect because of a third prevented, controlled
37
factor acting as confounder. for.
 Confounding
To be a confounding factor, TWO
conditions must be met:

Exposure Outcome

Third variable

Be associated with exposure, without being

the consequence of exposure

Be associated with outcome, independently

of exposure
Exposure assessment and
data quality
In all types of epidemiology, scientists need to
measure both exposures and outcomes.

In nutritional epidemiology, assessment of

exposure poses particular problems because
of the complexity of the human diet that
makes its measurement a major challenge for
nutritional epidemiologists. The majority of
methods rely upon subjects providing
accurate information about their current or
past diet.
Limitations in nutritional
epidemiology research
Lack of practical methods to measure diet
for large number of subjects

Dietary assessment methods must be:

Reasonably accurate
Relatively inexpensive
Diets of persons within one country are
too homogeneous to detect relationships
with disease.
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Thank you!

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