Anaemia, Fluorosis, IDD, Lathyrism

Nutritional Health Problems - By Dr. Sujatha Sathananthan

1. Nutritional Health Problems Dr.S.Sujatha MD.,DPH., Assistant Professor, Department of Community Medicine, Chengalpattu Medical College.

2. ??? 4/29/2018 2 Chengalpattu Medical College

3. Anaemia is defined by WHO as a “condition in which the haemoglobin content of blood is lower than normal as a result of a deficiency of one or more essential nutrients, regardless of the cause of such deficiency”. Anaemia is established if the haemoglobin is below the cut-off points recommended by WHO. 3 Definition of Anaemia 4/29/2018 Chengalpattu Medical College

4. g/dl (Venous blood) MCHC (percent) Adult males 13 34 Adult females, non-pregnant 12 34 Adult females, pregnant 11 34 Children, 6 months to 6 years 11 34 Children, 6 to 14 years 12 34 4 Cut-off points for the diagnosis of anaemia (WHO) 4/29/2018 Chengalpattu Medical College

5. Etiology 4/29/2018 5 Chengalpattu Medical College

6. 4/29/2018 6 Chengalpattu Medical College

7. Occurs in 3 stages: First Stage : Decreased storage without any other detectable abnormalities Second Stage : stores are exhausted, serum Ferritin level decreases. Third Stage : Decrease in Hemoglobin percentage Functional disturbances : decrease in resistance to infection, increase morbidity & mortality, decreased work performances, impaired cell mediated immunity Iron Deficiency 4/29/2018 7 Chengalpattu Medical College

8. Signs & Symptoms 4/29/2018 8 Chengalpattu Medical College

9. Symptoms Easy fatigue and loss of energy Unusually rapid heart beat, particularly with exercise Shortness of breath and headache, particularly with exercise Difficulty concentrating Dizziness Pale skin Leg cramps Insomnia 4/29/2018 9 Chengalpattu Medical College

10. Anemia Caused by Iron Deficiency People with an iron deficiency may experience these symptoms : A hunger for strange substances such as paper, ice, or dirt (a condition called pica ) Upward curvature of the nails, referred to as koilonychias Soreness of the mouth with cracks at the corners Anemia Caused by Vitamin B12 Deficiency A tingling, "pins and needles" sensation in the hands or feet Lost sense of touch A wobbly gait and difficulty walking Clumsiness and stiffness of the arms and legs Dementia Hallucinations, paranoia, and schizophrenia 4/29/2018 10 Chengalpattu Medical College

11. PICA FATIGUE DIZZINESS HEADACHE IRRITABILITY HAIR LOSS DYSPHAGIA SYMPTOMS 4/29/2018 11 Chengalpattu Medical College

12. Signs of Anaemia   Brittle nails   Koilonychia (spoon shaped nails)  Atrophy of the papillae of the tongue  Angular stomatitis  Brittle hair   Dysphagia and Glossitis  Plummer vinson / kelly patterson 4/29/2018 12 Chengalpattu Medical College

13. PALLOR KOILONYCHIA/ PLATYNYCHIA ATROPHIC STOMATITIS SPLENOMEGALY Clinical findings 4/29/2018 13 Chengalpattu Medical College

14. 4/29/2018 14 Chengalpattu Medical College

15. Hemoglobin Concentration : relative index of iron deficiency. ( early Anemia if Hb is 10-11g% & marked anemia Hb is < 10g%). Serum Iron concentration : useful index ( Normal 0.8 to 1.8mg /L) Serum Ferritin level : Gold standard & sensitive tool for evaluation and reflects the size of the iron status ( < 10Micrgms/L) Serum Transferrin Saturation : 16% - 30% Evaluation of iron status 4/29/2018 15 Chengalpattu Medical College

16. Management Determine the Cause of Iron Deficiency The etiology is often multifactorial ; even when there is an obvious cause, investigation of serious underlying causes ( e.g.cancer in adults) is recommended. Aim of Treatment Normalize hemoglobin levels and red cell indices; replenish iron stores. Individualize disease-specific management depending on underlying cause. Lifestyle Management It is recommended that patients with iron deficiency receive dietary advice . 4/29/2018 16 Chengalpattu Medical College

17. Non Pharmocological Management Tea and coffee inhibit iron absorption when consumed with a meal or shortly after a meal. Vitamin C (ascorbic acid) is also a powerful enhancer of iron absorption from nonmeat foods when consumed with a meal. Germination and fermentation of cereals and legumes improve the bioavailability of iron by reducing the content of phytate , a substance in food that inhibits iron absorption. Promote and support exclusive breastfeeding for about 6 months followed by breastfeeding with appropriate complementary foods, including iron-rich through the second year of life. 4/29/2018 17 Chengalpattu Medical College

18. 4/29/2018 Chengalpattu Medical College 18

19. Iron Supplementation Iron fortification Changing dietary habits Controlling parasitic infection Deworming Avoid open air defecation Avoid bare foot Nutrition education – To improve dietary intakes in family for receiving needed/macro/micro nutrients as protein, iron and vitamins like folic acid, B12 and vitamin C, etc. 19 Management of Iron Deficiency Anaemia 4/29/2018 Chengalpattu Medical College

20. D Dietary advice Deworming 4/29/2018 20 Chengalpattu Medical College

21. 4/29/2018 Chengalpattu Medical College 21

22. National Iron + Initiative Bi-weekly iron supplementation for preschool children 6 months to 5 years Weekly supplementation for children from 1st to 5th grade in Govt. & Govt. Aided schools Weekly supplementation for out of school children (5–10 years) at Anganwadi Centres Weekly supplementation for adolescents (10–19 years) Pregnant and lactating women Weekly supplementation for women in reproductive age IFA tablet has been made blue to distinguish it from the red IFA tablet for pregnant and lactating women. 4/29/2018 Chengalpattu Medical College 22

23. 4/29/2018 Chengalpattu Medical College 23

24. Iron plus Initiative 4/29/2018 Chengalpattu Medical College 24

25. 4/29/2018 Chengalpattu Medical College 25

26. 4/29/2018 Chengalpattu Medical College 26

27. W eekly Iron and Folic acid S upplimentation P rogramme for A dolescents Also known as WIFS-Blue campaign . Nodal agency- Ministry of H&FW Beneficiaries- Adolescent girls/boys enrolled in school, 6 th - 12 th std. Adolescent girls not enrolled in schools Services : IFA tablet to target population on weekly basis on a fixed day Biannual deworming (February and August) IMPLEMENTATION In-school students Ministry of education Out of school students Ministry of Social Welfare 4/29/2018 Chengalpattu Medical College

28. WIFS –Weekly Iron Folic acid Supplementation 4/29/2018 Chengalpattu Medical College 28

29. WIFS - Advantages Improved concentration in school, and school performance Feeling stronger and less tired, Increased energy levels and output in day to day work, Increased appetite, Improved overall capacity to work and earn Better sleep Improved skin appearance, Regularization of menstruation Building pre-pregnancy health 4/29/2018 Chengalpattu Medical College 29

30. Key activities Both boys and girls to be given IFA and Albendazole Tablets 6th to 12th class students to be covered Weekly Fixed day approach Supervised consumption of weekly IFA tablet to be ensured IFA tablet to be given after meals ( Mid-Day Meal or Lunch) Screen students for pallor and refer Bi-annual ( six months apart) distribution of Albendazole tablets HE sessions to be conducted regularly Filling of Individual compliance cards 4/29/2018 Chengalpattu Medical College 30

31. ????? 4/29/2018 31 Chengalpattu Medical College

32. Spectrum of IDD Goiter Loss of 13 IQ points, Leading Cause of Mental handicap Cretinism Spontaneous Abortions, Stillbirths, Birth Defects Defects of Speech & Hearing, Squint, Psychomotor defects 4/29/2018 32 Chengalpattu Medical College

33. Hypothyroidism Symptoms Fatigue (sluggishness) Mental impairment with decreased concentration and memory Depression Muscle aches – fibromyalgia Joint pains Constipation Decreased sexual energy Cold intolerance Signs Weight Gain Dry, cold(and thick) skin Fluid retention, myxedema Hair loss with dry hair Slow reflexes Hypothermia Manifestations of congestive heart failure 4/29/2018 33 Chengalpattu Medical College

34. Cretinism,Mental retardation Arrested physical &mental development Dystrophy of bones & cartillages Myxodema Low BMR 4/29/2018 34 Chengalpattu Medical College

35. Brain Cell Growth Iodine Deficiency Iodine Sufficiency Iodine Deficiency is the single most common cause of preventable mental retardation 4/29/2018 35 Chengalpattu Medical College

36. Brain cell branching Diminished brain cell branching due to iodine deficiency Diminished branching  Less connections  Lower IQ 4/29/2018 36 Chengalpattu Medical College

37. LOSS OF IQ : IMPLICATIONS The Intelligence Quotient (IQ) score of children living in an iodine deficient environment is nearly 13 IQ points less than those living in iodine sufficient environments IMPLICATIONS OF LOSS OF IQ Poor scholastic performance Frequent failures / grade repetitions Absenteeism / Dropouts Impact : Retarded social & economic growth 4/29/2018 37 Chengalpattu Medical College

38. Chengalpattu Medical College Iodine Deficiency , Goitre - Visible Swelling No Pain , Not a cause of Mortality , Cosmetic problem Cretinism IDD – The Hourglass Historic View Current View Mental & Physical growth Loss of Energy-hypothyroidism Learning Disability, Poor Motivation Child Development and Child Survival 4/29/2018 38

39. 4/29/2018 39 Chengalpattu Medical College

40. Prevalence of Goitre Prevalence of Cretinism Urinary iodine excretion Prevalence of Neonatal hypothyroidism Thyroid Function tests Neonatal Hypothyroidism is a sensitive indicator of environmental iodine deficiency Serum T4 is more sensitive indicator among adults Epidemiological assessment 4/29/2018 40 Chengalpattu Medical College

41. Iodine Deficiency Disorder Control Programme National goiter control programme was started in 1962 Renamed it on 1992 as National iodine deficiency disorder control programme Replace the entire edible salt by iodide salt Double fortification of salt iodine and iron (35ppm and 1000ppm) 4/29/2018 41 Chengalpattu Medical College

42. N ational iodine deficiency disorder control programme The beginning- Kangra valley study (1956-72) National Goitre Control Programme launched in 1962, at the end of 2 nd 5-year plan by Ministry of H&FW , GoI . Focuses on use of Iodised Salt – Replace of common salt with iodised salt, Cheapest method to control IDD. Use of Iodized oil Injection to those suffering from IDD, Oral administration as prophylaxis in IDD severe areas Rationale No State or UT in India is free from IDD, as evident from the surveys carried by ICMR Iodine deficiency leads to a spectrum of disorders mostly affecting physical and mental development The fact that human brain development is completed by 3 years of age , iodine deficiency in early age leads to permanent and irreversible damage. Fortification of salt is a preventive programme , can be considered as a ‘vaccine’ Dr V Ramalingaswami (1921 - 2001) 4/29/2018 42 Chengalpattu Medical College

43. J ourney of the programme ….. The turning point- 1983- Universal iodisation of salt (30 ppm at manufacture level and 15ppm at consumption level) 1992- programme renamed as ‘ National iodine deficiency disorder control’ Objectives Surveys to assess t he magnitude of IDD. Supply of iodised salt Resurveys 5yearly to assess impact of iodised salt & IDD Lab monitering of iodised salt Health education. Strategy Iodise entire edible salt in the country by 1992. Ban of non-iodised salt under PFA act (1954). 4/29/2018 43 Chengalpattu Medical College

44. 4/29/2018 44 Chengalpattu Medical College

45. ????? 4/29/2018 45 Chengalpattu Medical College

46. Recommended level of fluorides in drinking water in India - 0.5 to 0.8 mg per litre Dental fluorosis occurs : > 1.5 mg/ litre Skeletal fluorosis occurs: 3.0 – 6.0 mg/ litre Crippling fluorosis occurs : >10 mg/ litre Fluorine deficiency causes : DENTAL CARIES Fluoride 4/29/2018 46 Chengalpattu Medical College

47. Children living in high fluoride zone are bound to get dental discoloration which may be seen even in deciduous teeth. Initially glistening white teeth become dull and yellow-white spots appear on the surface of teeth. Gradually these spots turn brown and presents itself in brown streaks which are closer to the tip of the teeth. In late stages the whole teeth become black . Teeth may be pitted or perforated and may even get chipped off. In endemic zones people lose their teeth at an early age and may become edentate. Dental Fluorosis 4/29/2018 47 Chengalpattu Medical College

48. 4/29/2018 48 Chengalpattu Medical College

49. Degrees of dental fluorosis Very mild to mild (slight mottling of teeth) Moderate (obvious mottling of teeth) Severe (severe mottling of teeth ) 4/29/2018 49 Chengalpattu Medical College

50. It affects young as well as old. The symptoms include severe pain and stiffness in the backbone, joints and/or rigidity in hip bones. X-ray examinations of the bones reveals thickening and high density of bones. In some patients with calcium deficiency osteomalacia type changes are seen. Constriction of vertebral canal and intervertebral foramen - pressure on nerves leads to paralysis. Skeletal Fluorosis 4/29/2018 50 Chengalpattu Medical College

51. Photograph showing skeletal fluorosis patient Radiograph of a patient of skeletal fluorosis 4/29/2018 51 Chengalpattu Medical College

52. Non-Skeletal Fluorosis In the fluorosed muscles, actin and myosin filaments are destroyed and mitochondria lose their structural integrity thereby providing evidence of depletion of muscle energy. The erythrocyte membrane loses its calcium content in presence of high fluoride. Non-ulcer dyspeptic complaints are manifested by consuming high F in water and food. Infertility due to oligo spermia and azoospermia is commonly seen in fluorotic belts. 4/29/2018 52 Chengalpattu Medical College

53. UNICEF’s Clinical Test Three simple clinical tests Forward flexion of spine Chin to Chest test Hands on the occiput test Normal person can do. Person with skeletal fluorosis can not. Left figures Normal, Right Abnormal DIAGNOSIS 4/29/2018 53 Chengalpattu Medical College

54. Tests for Skeletal Fluorosis COIN TEST: The subject is asked to lift a coin from the floor without bending the knee. A fluorotic subject would not be able to lift the coin without flexing the large joints of lower extremity. CHIN TEST : The subject is asked to touch the anterior wall of the chest with the chin. If there is pain or stiffness in the neck, it indicates the presence of fluorosis . STRETCH TEST : The individual is made to stretch the arm sideways, fold at elbow and touch the back of the head. When there is pain and stiffness, it would not be possible to reach to the occiput indicating presence of Fluorosis. 4/29/2018 54 Chengalpattu Medical College

55. Community Flourosis Index W.H.O. Monograph on Fluoride and Human Health (1970) has enumerated the use of Community Fluorosis Index in determining the optimal Fluoride Intake . The Community Fluorosis Index (CFI) is a way of measuring the burden of dental fluorosis in a population. Instead of measuring the overall prevalence of fluorosis (i.e., what percentage of people have fluorosis), it takes into account the severity of the fluorosis that is occurring. The CFI is thus a measurement of both prevalence + severity. An individual's fluorosis score is based on the most severe form of fluorosis found on two or more teeth. 4/29/2018 55 Chengalpattu Medical College

56. 4/29/2018 56 Chengalpattu Medical College

57. 4/29/2018 57 Chengalpattu Medical College

58. Community Fluorosis Index The CFI is calculated based on the following point scale for the different categories of dental fluorosis : Questionable Fluorosis = 0.5 points Very Mild Fluorosis = 1 point Mild Fluorosis = 2 points Moderate Fluorosis = 3 points Severe Fluorosis = 4 points After determining how many children have these types of fluorosis , the points are added up and divided by the number of children examined. 4/29/2018 58 Chengalpattu Medical College

59. Scores and their significance Range Significance of scores 0.0-0.4 Negative 0.4-0.6 Borderline 0.6-1.0 Slight 1.0-2.0 Medium 2.0-3.0 Marked 3.0-4.0 Very Marked Only when the CFI value is greater than 0.6, Fluorosis is considered to be a public health problem in that area 4/29/2018 59 Chengalpattu Medical College

60. Since the major source of fluoride is drinking water, de-fluoridation is the best preventive measure which can be carried out at domestic as well as community level Nutritional interventions like high intake of vitamin C and Calcium also helps reduce the problem PREVENTION 4/29/2018 60 Chengalpattu Medical College

61. Nalgonda technique Adapted and developed in India by the National Environmental Engineering Research Institute (NEERI) and developed to be used at both the community and household levels. The process is aluminium sulfate based coagulation-flocculation sedimentation, where the dosage is designed to ensure fluoride removal from the water 4/29/2018 61 Chengalpattu Medical College

62. Precipitation methods are commonly used for de-fluoridation. Lime treatment routinely used for hardness removal can remove F particularly when water is having high Mg hardness. Alum is used at domestic level in high doses to remove the F. In India scientists have developed a method known as “ Nalgonda technique” in which based on the amount of F in drinking water and alkalinity of the Water (expressed as mgCaCO3), amount of Alum to be mixed with water is calculated. Resins and other filter beds are also available filtering through which reduces the amount of F in water . De-fluoridation 4/29/2018 62 Chengalpattu Medical College

63. The fill and draw type Nalgonda technique for domestic and community defluoridation 4/29/2018 63 Chengalpattu Medical College

64. Human teeth (and bones) are primarily composed of the mineral calcium hydroxyapatite . Calcium hydroxyapatite has the chemical formula: Ca 5 [(PO 4 ) 3 OH]. One of the main components of this mineral is the hydroxyl ion. Fluoride substitutes for the hydroxyl ion, producing calcium fluoroapatite , with the chemical formula: Ca 5 [(PO 4 ) 3 F] Calcium fluoroapatite is chemically stable than calcium hydroxyapatite in acid environment of the mouth. This means that a higher concentration of calcium fluoro apatite in tooth enamel decreases tooth dissolution, and therefore can decrease the incidence of tooth decay. How does fluoride treatment prevent tooth decay ? 4/29/2018 64 Chengalpattu Medical College

65. Riddle of the sphinx: " What has one voice, and is two-footed and three-footed four-footed?" 4/29/2018 65 Chengalpattu Medical College

66. Lathyrism , a neurodegenerative disorder: limping (two-footed) walking withstick (three-footed) crawling (four-footed). 4/29/2018 66 Chengalpattu Medical College

67. LATHYRISM Kesari dal (Seeds of Lathyrus sativus ) ( Lak dal / Batra / Teora dal / Gharas,Matra ) Toxin- (BOAA) Beta Oxalyl Amino Alanine Human- Neurolathyrism Spastic paralysis of lower limbs Animals- Osteolathyrism ( Odolathyrism ) 4/29/2018 67 Chengalpattu Medical College

68. LATHYRISM MP ( Reva , Satna ), UP, Bihar, Orissa, WB, MH, Rajasthan, Assam,Gujarat .. 15-45 years age group Water soluble toxin 4/29/2018 68 Chengalpattu Medical College

69. CLINICAL MANISFESTATION Latent stage No stick stage One stick stage Two stick stage Crawler stage 4/29/2018 69 Chengalpattu Medical College

70. INTERVENTIONS Vitamin C Prophylaxis 500-1000mg/day ------7days Banning crops Removal of toxin: Steeping method and Parboiling method Health Education Genetics- low toxin strains Socio-economic improvement 4/29/2018 70 Chengalpattu Medical College

71. 4/29/2018 Chengalpattu Medical College 71 THANK YOU THANK YOU