NUTRITIONAL PROBLEMS IN INDIA & COMMUNITY NUTRITION PROGRAMMES

Mohammed Mubarak. M Ist year MSc Nursing Govt. College of Nursing. Kottayam

MAJOR HEALTH PROBLEMS IN INDIACOMMUNICABLE DISEASE PROBLEM POPULATION PROBLEM ENVIRONMENTAL SANITATION PROBLEM MEDICAL CARE PROBLEM NUTRITIONAL PROBLEM

CAUSE OF NUTRITIONAL PROBLEMPOOR NUTRITION

UNDER NUTRITION (MALNUTRITION) OVERNUTRITION

The World Bank estimates that India is ranked 2nd

in the world of the number of children suffering from malnutrition Undernutrition is found mostly in rural areas 10 percent of villages and districts accounting for 27-28 percent of all underweight children children of scheduled tribes have the poorest nutritional status and the highest wasting

DETERMINANTS OF MALNUTRITIONMATERNAL MALNUTRITION LOW BIRTH WEIGHT FAULTY CHILD FEEDING PRACTICES DIETARY INADEQUACY FREQUENT INFECTIONS LARGE FAMILIES HIGH FEMALE ILLITERACY TABOOS AND SUPERSTITIONS

FACTORS AFFECTING NUTRITIONAL STATUS

HIGH RISK GROUPPregnant women Lactating women Infants Preschool children Adolescent girls Elderly Socially deprived

NUTRITIONAL PROBLEMS IN INDIA

NUTRITIONAL PROBLEMS IN INDIAPROTEIN ENERGY MALNUTRITION LOW BIRTH WEIGHT XEROPHTHALMIA NUTRITIONAL ANEMIA IODINE DEFICIENCY DISORDERS FLUROSIS LATHYRISM OBESITY CARDIO VASCULAR DISEASES

75 percent of preschool children suffer from

iron deficiency anemia (IDA) 57 percent of preschool children have subclinical Vitamin A deficiency (VAD) Iodine deficiency is endemic in 85 percent of districts 11% of Indian population in India are overnourished over 30 million people with diabetics in 1985 and by next year (2010) India is projected to have 50.8 million diabetics India is hence considered as the country with the largest population of diabetics

PROTEIN ENERGY MALNUTRITIONPEM refers to the deficiency of energy and

protein in the body. 1-2% of preschool children in India suffer from PEM.

MAIN CAUSES OF PEM Inadequate intake of food both in quantity

and quality Infections (Diarrhea, Respiratory infections, measles, intestinal worms)

Contributing factors to PEMPOOR ENVIRONMENTAL CONDITIONS, LARGE FAMILY SIZE, POOR MATERNAL HEALTH, FAILURE OF LACTATION, PREMATURE TERMINATION OF BREAST

FEEDING, ADVERSE CULTURAL PRACTICES RELATED TO CHILD REARING AND WEANING, DELAYED SUPPLEMENTARY FEEDING

CLINICAL FORMS OF PEM MARASMUS KWASHIORKER

Marasmuscommon type of PEM observed among

children below 1 year of age. Caused by severe deficiency of nearly all nutrients especially protein and calories conditions are characterized by extreme wasting of the muscles and a daunt expression

Marasmus Extensive tissue and muscle wasting Dry skin Loose skin folds hanging over glutei and axilla, Fat wasting small for age sparse hair that is dull brown or reddish yellow, mental retardation behavioral retardation, low body temperature ( hypothermia), slow pulse and breathing rates.

Absence of edema

KwashiorkerKwashiorker occurs in children between 2-3

years of age Acute form of PEM due to deficiency of protein in the diet (Both in quantity and quality) Deficiency of micronutrients (Fe, Folic acid, Iodine, Selenium, and Vitamin C) Deficiency of antioxidants (albumin, Vitamin E, PUFA, Glutathione). kwashiorkor is identified as swelling of the extremities and belly, which is deceiving to their actual nutritional status

KWASHIORKERMalnourished child with pedal edemas, Growth failure, Moon face, Distended abdomen,

Ascitis(abnormal accumulation of fluid)

Enlarged liver with fatty infiltrates, thinning of hair, Loss of teeth, Skin depigmentation Dermatitis, Irritability Anorexia

Assessment of PEM

Gomez Classification

Weight for age =

Weight of the child

100 Weight of normal child of the same age110% Normal Nutritional Status 89% Mild malnutrition (1st 74% Moderate Malnutrition

Between 90 Between 75 degree) Between 60 (2nd degree) Under 60% degree)

Severe Malnutrition (3rd

Preventive Measures of PEMHealth promotion Measures Promotion of breast feeding, low cost

weaning food, nutrition education, family planning and birth spacing, Protein energy rich food,(milk, egg, fresh fruits), immunization, food fortification Early diagnosis and treatment Rehabilitation

LOW BIRTH WEIGHT

LOW BIRTH WEIGHTBirth weight less than 2500Gm.30% 0f

babies born in India are LBW

Causative factorsMaternal malnutrition and anemia. Illness and infections during pregnancy, High parity, Close birth intervals

Factors Modifying Prevalence of LBWMore Institutional deliveries Improving No.of ANCs (minimum: >5) Improving Quality of ANC

Includes: No.ofANCs, TT, weight, BP, examination of blood, examination of urine

XEROPHTHALMIA(DRY EYE)Disease

due to deficiency of Vitamin A Also Called Xeroma Absence of tears Xerophthalmia is most common in children aged 1-3 years Cornea and conjunctiva become horny and necrosed

Bitots Spots Collection of dried epithelium, micro organisms etc. forming shiny grayish white spot on the cornea A sign of Vitamin A deficiency

KERATOMALACIA

Ulceration and softening of Cornea due to deficiency of vitamin A

Bilateral Blindness

Risk factorsIgnorance Faulty feeding practices Infections Diarrhea Use of skimmed milk(totally devoid of

vitamin a)

PreventionShort term action oral Administration of

large dose of Vitamin A (retinol Palmitate) Medium term action Food fortification with Vitamin A. Eg:Dalda,Sugar,Salt,Tea etc Long term action Promote BF, consumption of Green Leafy Vegetables, Immunisation to infections

NUTRITIONAL ANEMIAA Condition in which the Hb content of blood

lower than normal as a result of a deficiency of one or more essential nutrients Primarily due to lack of absorbable iron in the diet

ANAEMIA IN FEMALES IN INDIA

Pregnant Women

Adolescent girls

Causes of Iron deficiency anemiaInadequate intake of iron Poor bioavailability (only less than 5 percent

is absorbed) Excessive loss of iron (menstruation, rapid pregnancies, hookworm infestations, other illnesses)

Effects of anemiaIncreases the risk of maternal and fetal

mortality and morbidity Increase susceptibility to infection due to impaired cellular response and immune functions Reduction of work performance and productivity

InterventionsIron and folic acid supplementation Nutritional anemia prophylaxis programme

(daily Fe & folic acid supplementation to Pregnant Women lactating mothers & Children under 12 years) Iron fortification - Fortification of salt with iron Control of parasite and nutrition education

IODINE DEFICIENCY DISORDERS (IDD)IDD refers to a spectrum of disabling

conditions arising from an inadequate dietary intake of iodine.

IDD affects the health of humans from fetal

stage to adulthood

CAUSES OF IDDDeficient iodine Intake Consuming foods with low

Iodine content, Crops grown in iodine depleted soil Increased demand for Iodine in the body Demand of

Iodine is increased during the stage of rapid growth (Infancy, Puberty, pregnancy, lactation), Demand exceeds supply results in deficiency. Presence of Goitrogens goiter producing substances

naturally present in some foods (cabbage, cauliflower etc.) interfere with Iodine utilization

IODINE DEFICIENCY DISORDERS (IDD) Endemic Goiter Cretinism

Endemic Goiter Also called Derbyshire Neck Enlargement of thyroid gland causing swelling in front part of the neck Due to lack of iodine in the diet Goiter belt Himalayan region Graded from 0 4 Common among girls than boys

CretinismSevere form of IDD Occurs during fetal stage Interfere with brain development causing

brain damage and death Result in Growth failure, MR, Speech and hearing defects

FLUROSISOccurs due to consumption of excessive

amount of fluorine through drinking water Two types of flurosis Dental Flurosis Skeletal flurosis

Dental flurosisSeen in children 5- 7 years

of age Teeth lose their shiny appearance and chalk white patches develop on them Changes are called mottling of enamel In severe cases loss of enamel gives teeth a corroded appearance Dental flurosis is confined to permanent teeth and develops only during the

Skeletal flurosis Seen in older

adults Heavy fluoride deposition on skeleton Manifested as pain numbness &tingling sensation of the extremities, stiffness of neck Genu Valgum A form of skeletal deformity associated with flurosis The lower limbs appear as

Prevention of FlurosisKeep the drinking water fluorine level below

1mg/lit Deflouridation of water using Nalgonda Technique (Flocculation, Sedimentation & filtration) Prevent use of fluoride toothpaste in areas of endemic flurosis Deficiency of flurine?

LATHYRISMDisease occur by

consuming large quantities of Lathyrus sativus (Kesari dhal) Lathyrism in human is referred as Neurolathyrism The disease presents as Crippling disease of nervous system characterized by gradually developing spastic paralysis of lower limbs

LATHYRISMIt contains a toxin called Beta oxalyl amino

Alanine (BOAA) Lathyrus Kesari Dhal) is good source of protein. It is relatively cheaper.

InterventionRemoval of toxin Steeping method

Soaking the pulse in hot water for about 2 hours and

the soaked water is drained off completely

Genetic Approach Development of low toxin varieties of Lathyrus

Banning the crop The Prevention of food adulteration act in India has

banned Lathyrus in all forms

OBESITYMost Prevalent form of malnutrition Abnormal growth of adipose tissue due to

enlargement of fat cells(Hypertrophic),Increase in no. of fat cells (hyperplasic)or Combination of both

OBESITYObesity - When the body weight is 20%

more than the desirable weight. Over weight - When the body weight is between 10-20% more than the desirable weight

Factors contributing to obesity Age Sex Genetic factors Physical Inactivity Socio economic status Eating habits Psycho social factors Alcohol

The direct cause of overweight in India is lack of physical activity due to sedentary life style, loss of traditional diet, faulty diet, high stress high rate of economic growth

BMI

BMI = Height in kilogram

(Weight in Meter)220-25 IDEAL 26-30 OVERWEIGHT 31-40 OBESE 40+ VERY OBESE

Control of obesityEat food according to bodys requirement At least 3-4 hrs intervals between meals Avoid in between snacks Eat more leafy vegetables which contain high

fiber Avoid intake of fatty and fried foods Regular Physical exercise

CARDIO VASCULAR DISEASESClassified as one of the Food habit related

Illness Change in food habits and lifestyle has increased the risk of CVD in Indian population mostly in Middle Class and upper middle class groups.

CANCER80 % of cancer due to environmental factors Dietary fat positive correlation with Colon cancer, breast cancer Dietary fiber Risk of colon cancer is inversely related Micro nutrients Lack of Vitamin C & Vitamin A arise the risk of stomach cancer and lung cancer. Food additives Saccharin, cyclamate, Coffee, aflatoxin associated with bladder cancer Alcohol liver cancer, Rectal Cancer

COMMUNITY NUTRITION PROGRAMMES

Integrated Child Development Service (ICDS)

INTEGRATED CHILD DEVELOPMENT SERVICE (ICDS) SCHEME

scheme was launched on 2nd October, 1975 (5th Five year Plan) in pursuance of the National Policy For Children started in 33 experimental blocks Success of the scheme led to its expansion to 2996 projects by the end of March 1994. Now the goal (Ninth Five Year Plan ) is universalization of ICDS throughout the country.

Beneficiaries

1. Children below 6 years 2. Pregnant and lactating women 3. Women in the age group of 15-44 years 4. Adolescent girls in selected blocks

Objectives 1. Improve the nutrition and health status of

children in the age group of 0-6 years 2. Lay the foundation for proper psychological, physical and social development of the child; 3. Effective coordination and implementation of policy among the various departments 4. Enhance the capability of the mother to look after the normal health and nutrition needs through proper nutrition and health education.

The Package of services provided by ICDS1. Supplementary nutrition, Vitamin-A, Iron and

Folic Acid, 2. Immunization, 3. Health check-ups, 4. Referral services, 5. Treatment of minor illnesses; 6. Nutrition and health education to women; 7. Pre-school education of children in the age group of 3-6 years, and 8. Convergence of other supportive services like water supply, sanitation, etc

VITAMIN A PROPHYLAXIS PROGRAMME(1970)Programme launched by Ministry of H&FW Component of National programme for

control of blindness.1968,1976 Single massive dose of oily preparation of Vitamin A containing 200000 IU orally to all preschool children in the community every 6 months through peripheral health workers

PROPHYLAXIS AGAINST NUTRITIONAL ANAEMIALaunched by Govt.of India during 4th five

year plan Distribution of iron and folic acid tablets to pregnant women and young children (1-12 years MCH centres and ICDS projects implement this programme

SCHEME FOR ADOLESCENT GIRLS (KISHORI SHAKTI YOJNA)A scheme for adolescent girls in ICDs was

launched by the Department of Women and Child Development, Ministry of Human Resource Development in 1991. Targeted All adolescent girls in the age group of 11-18 years

SCHEME FOR ADOLESCENT GIRLS (KISHORI SHAKTI YOJNA)

common services 1. Watch over menarche, 2. Immunization, 3. General health check-ups once in every sixmonths, 4. Training for minor ailments, 5. De-worming, 6. Prophylactic measures against anemia, goiter, vitamin deficiency, etc., and 7. Referral to PHC. District hospital in case of acute need.

IODINE DEFICIENCY DISORDER PROGRAMMELaunched in 1962 Focuses on Use of Iodised Salt Replace of common salt

with iodised salt, Cheapest method to control IDD Use of Iodized tablets iodine tablets administered to school children (not widely accepted) Use of Iodized oil 1ml Injection of Iodized oil to those suffering from IDD, Oral administration as prophylaxis in IDD severe areas

MID-DAY MEAL PROGRAMMEAlso known as School launch programme Programme in operation since 1961 ObjectiveTo attract more children for admission to

schools

Principles of Mid Day Meal programmeThe meal should be supplement and not a

substitute to home diet. The meal should supply at least one third of the total energy requirement and half of the protein needed The cost of meal should be reasonably low. The Meal should be prepared easily in schools, no complicating cooking procedures involved Locally available foods should be used The menu should be frequently changed

Mid Day Meal programme RecommendationsCereals Pulses Oils and fats Leafy vegetables

75gm/day/child 30 8 30

30 Non leafy vegetables

BALWADI NUTRITION PROGRAMMENutritional support to pre school children Started on 1970 Under the Department of Social welfare For children age group 3-6 years in rural areas Programme implemented through Balwadis Food supplement

300kcal and 10grams of protein per child per

day

This system was called provision of dry

NATIONAL PROGRAMME FOR NUTRITION SUPPORT TO PRIMARY EDUCATION

rations. Government of India will provide grains free of cost and the States will provide the costs of other ingredients, salaries and infrastructure On November 28, 2001 the Supreme Court of India gave direction that made it mandatory for the state governments to provide cooked meals instead of dry rations

Successfully involved private sector

AKSHAYA PATRA AND PRIVATE SECTOR PARTICIPATION IN MIDDAY MEALS

participation in the programme The programme is managed with an ultra modern centralized kitchen that is run through a public/private partnership. Food is delivered to schools in sealed and heat retaining containers just before the lunch break every day

Thiswas introduced in May, 2001 in selected

EMERGENCY FEEDING PROGRAMME 2001

states (Orissa) Emergency Feeding Programme,is a foodbased intervention targeted for old, infirm and destitute persons belonging to BPL households to provide them food security in their distress conditions. Cooked food containing, rice- 200gms, Dal (pulse)- 40 gms, vegetables- 30 gms is provided in the diet of each EFP beneficiary daily by the Government.

VILLAGE GRAIN BANKS SCHEMEImplemented by the Ministry of Tribal Affairs to provide safeguard against starvation

during the period of natural calamity or during lean season when the marginalized food insecure households do not have sufficient resources to purchase rations.

WHEAT BASED NUTRITION PROGRAMME (WBNP)Implemented by the Ministry of Women &

Child Development providing nutritious/ energy food to children below 6 years of age and expectant /lactating women from disadvantaged sections Implemented through ICDS

SC/ST/OBC HOSTELSintroduced in October, 1994 by Ministry of

Consumer Affairs, Food & Public The residents of the hostels having 2/3rd students belonging to SC/ST/OBC are eligible to get 15 kg food grains per resident per month.

SAMPOORNA GRAMIN ROZGAR YOJANA50 lakh tones of food grains is to be allotted

to the States/UTs free of cost by Ministry of Rural Development

NATIONAL FOOD FOR WORK PROGRAMMETo provide supplementary wage employment

and food security Implemented in tribal belts. The scheme will provide 100 days of employment at minimum wages for at least one able-bodied person from each household in the country

GRAIN BANK SCHEMEMinistry of Consumer Affairs, Food & Public

Distribution to establish Grain Banks in chronically food scarce areas.

PULSE MISSIONpulse production has been stagnant for five

decades.

Pulse Mission (Indias Food Security Mission)

aimed at increasing pulse production.tones by2011-12

Aimed to improve pulse production by 2 million

NATIONAL WATER SUPPLY AND SANITATION PROGRAMMELaunched in 1954 Provide safe water supply and adequate

drainage facilities for the entire urban and rural population of the country

MINIMUM NEEDS PROGRAMME Launched on 1974

Objective To provide basic minimum needs and thereby improve the living standards of people It Includes Rural Health Rural water Supply Rural electrification Elementary education Adult education Nutrition Environmental improvement of urban slums House for landless laborers

20 POINT PROGRAMME 1975Objectives: Eradication of poverty, raising productivity, reducing inequality, improving quality of life.

National Children's Fund 1979

This Fund Provides support to the voluntary organizations that help the welfare of children.

National Plan of Action for Children1990 United Nations Children's Fund National Rural Health Mission2005-2012

National Rural Health Mission20052012Reduce the infant mortality rate (IMR) and

the maternal mortality ratio (MMR) To have universal access to public health services Prevent and control both communicable and non-communicable diseases, including locally endemic diseases To have access to integrated comprehensive primary healthcare Create population stabilization, as well as gender and demographic balance Revitalize local health traditions and mainstream AYUSH Finally, to promote healthy life styles

INDIRECT PROGRAMMES NATIONAL CANCER CONTROL PROGRAMME 1975-76 NATIONAL DIABETES CONTROL PROGRAMME POVERTY ALLEVIATION PROGRAMMES ENVIRONMENTAL SANITATION PROTECTED WATER SUPPLY PROGRAMME LITERACY PROGRAMME