Nutritional Problems in India

1. NUTRITIONAL PROBLEMS JENITA JOYCE JOHN I YEAR M.Sc., (N) APOLLO CON, CHENNAI

2. INTRODUCTION Nutrition  is the selection of  foods and preparation of foods, and their ingestion to be assimilated by the body. By practicing a healthy diet, many of the known health issues can be avoided. The  diet of an organism is what it eats, which is largely determined by the perceived palatability of foods.

3. HISTORY OF NUTRITION 400 B.C. -- Hippocrates, the "Father of Medicine", said to his students, "Let thy food be thy medicine and thy medicine be thy food".  He also said  A wise man should consider that health is the greatest of human blessings. One story describes the treatment of eye disease, now known to be due to a vitamin A deficiency, by squeezing the juice of liver onto the eye. Vitamin A is stored in large amounts in the liver.

4. 1747 Dr . James Lind, a physician in the British Navy, performed the first scientific experiment in nutrition. At that time, sailors were sent on long voyages for years and they developed scurvy. In his experiment, Lind gave some of the sailors sea water, others vinegar, and the rest limes.  Those given the limes were saved from scurvy. As Vitamin C wasnt discovered until the 1930s , Lind didnt know it was the vital nutrient.  Early 1800s It was discovered that foods are composed primarily of four elements: carbon, nitrogen, hydrogen and oxygen, and methods were developed for determining the amounts of these elements.

5. 1930s William Rose discovered the essential amino acids, the building blocks of protein . 1940s The water soluble B and C vitamins were identified 1950s to the Present -- The roles of essential nutrients as part of bodily processes have been brought to light. For example, more became known about the role of vitamins and minerals as components of enzymes and hormones that work within the body

6. TERMINOLOGIES NUTRITION - The word Nutrition is the science of foods, the study of nutrients and other substances therein, their action, interaction and balance in relationship to disease .

7. HEALTH – It is the state of complete physical, mental and emotional well being and not merely the absence of disease or infirmity. NUTRIENTS – These are the components of food that help to nourish the body. The basic nutrients are CHO, proteins, vitamins, lipids (fats), minerals and water. NUTRITIONAL STATUS – It is the condition of the body as it relates to consumption and utilization of food .

8. Malnutrition – defined as a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients Undernutrition - condition that results when insufficient food is consumed over an extended period of time Overnutrition – pathological state resulting from the consumption of excessive quantity of food over an extended time Imbalance – pathological state resulting from disproportion among essential nutrients with or without the absolute deficiency of any nutrient Specific deficiency – pathological state resulting from a relative or absolute lack of specific nutrients

9. FOOD GUIDE PYRAMID

10. ASSESSMENT OF NUTRITIONAL STATUS Clinical Examination Anthropometry Biochemical evaluation Assessment of dietary intake Vital statistics – morbidity and mortality Ecological factors

11. NUTRITIONAL PROBLEMS

12. NUTRITION PROBLEMS IN INDIA WHO IS AT RISK?? PREGNANT WOMEN LACTATING WOMEN INFANTS PRESCHOOL CHILDREN ADOLESCENT GIRLS ELDERLY . Vijayaraghavan

13. PROTEIN ENERGY MALNUTRITION Protein–energy malnutrition  (or  protein–calorie malnutrition ) refers to a form of  malnutrition where there is inadequate   protein and calorie intake It is considered as the primary nutritional problem in India PEM is due to the “food gap” between the intake and requirement Causes childhood morbidity and mortality

14. PROTEIN ENERGY MALNUTRITION

15. CAUSES AND RISK FACTORS Inadequate intake of food Diarrhea Respiratory infections Measles Intestinal worms Infants and pre schoolers CONTRIBUTORY FACTORS Poor envt . Hygiene Large family size Poor maternal health Failure of lactation Premature termination of breast feeding Delayed supplementary feeding Use of over diluted cow’s milk

16. KWASHIORKOR Kwashiorkor is the most common and widespread nutritional disorder in developing countries. It is a form of malnutrition caused by not getting enough protein in the diet.

17. MARASMUS Marasmus is a severe form of malnutrition that consists of the chronic wasting away of fat, muscle, and other tissues in the body . Malnutrition occurs when the body does not get enough protein and calories. This lack of nutrition can range from a shortage of certain vitamins to complete starvation . Marasmus is one of the most serious forms of protein-energy malnutrition (PEM) in the world.

18. MARASMIC KWASHIORKOR A malnutrition disease, primarily of children, resulting from the deficiency of both calories and protein. The condition is characterized by severe tissue wasting, dehydration, loss of subcutaneous fat, lethargy, and growth retardation

19. KWASHIORKOR AND MARASMUS – A COMPARATIVE CHART KWASHIORKOR Acute illness/infections, measles, AGE, trauma, sepsis are some causes Protein is principal nutrient 18 months to 3 years Rapid, acute onset Some weight loss High mortality MARASMUS Severe prolonged starvation, chronic/recurring infections Calories and protein are principal nutrients 6 months to 2 years Chronic, slow onset Severe weight loss Low mortality unless related to underlying disease condition

20. COMPARISON OF CLINICAL FEATURES KWASHIORKOR Edema, pot belly, swollen legs Mild to moderate growth retardation Weight masked by edema Low subcutaneous fat Muscle atrophy Round face (moon face) Dry, flaky peeling skin Thin dry easily plucked hair Enlarged liver Xerophthalmia Anemia, diarrhea, infection MARASMUS No edema Weight loss upto 40% Severe growth failure Severe emaciation Severe loss of subcut fat Severe muscle atrophy Wrinkled face (old man’s face) Rare skin changes Common hair changes Mildly enlarged liver Anemia, diarrhea, infection

21. ASSESSMENT OF PEM Gomez Classification Weight for age (%) = Weight of child 100 Wt. of normal child of same age Between 90 – 110% Normal Nutritional Status Between 75 – 89% Mild malnutrition (1 st degree) Between 60 – 74% Moderate Malnutrition (2 nd degree) Under 60% Severe Malnutrition (3 rd degree)

22. WEIGH CALCULATION FORMULAE Infant – Weight (Kg) = Age in months + 9 2 Pre schooler – Weight (Kg) = 2 x (Age in years) + 5

23. PREVENTION Oral rehydration therapy helps to prevent dehydration caused by diarrhea Exclusive breast feeding for 6 months there after supplementary foods may be introduced along with breast feeds Immunization for infants and children Nutritional supplements Early diagnosis and treatment Promotion and correction of feeding practices Family planning and spacing of birth Periodic surveillance Nutritional rehabilitation

24. LOW BIRTH WEIGHT An LBW newborn is any newborn with a birth weight of less than 2.5kg (including 2.499kg) regardless of gestational age.

25. RISK FACTORS Maternal malnutrition Anemia CAUSES Illness/infections Short maternal stature Very young age High parity Close birth intervals IUGR Hard physical labor during pregnancy Smoking

26. PREVENTION Identification of mothers at risk – malnutrition, heavy work load, infections, disease and high BP Increasing food intake of mother, supplementary feeding, distribution of iron and folic acid tablets Avoidance if smoking Improved sanitation methods Improving health and nutrition of young girls Early detection and treatment of medical disorders – DM HTN Controlling infections – UTI, rubella, syphillis , malaria

27. MICRONUTRIENT DEFICIENCY

28. VITAMIN A DEFICIENCY Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A crude population measure of obesity is the body mass index (BMI), a person’s weight (in kilograms) divided by the square of his or her height (in meters). A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.

29. XEROPHTHALMIA Xerophthalmia i.e., dry eyes refers to all the ocular manifestations of vitamin A deficiency in man It is the most widespread and serious nutritional disorder leading to blindness

30. RISK FACTORS Poor SE status Faulty feeding practices Weaning PEM Infections 1-3 years CLINICAL FEATURES Corneal ulcers Softening of cornea Keratomalacia Bitot spot

31. PREVENTION AND CONTROL Administering large doses of vitamin A orally on a periodic basis Regular and adequate intake of vitamin A Fortification of certain food with vitamin A – sugar, salt, tea and skimmed milk

32. NUTRITIONAL ANEMIA Nutritional anemia is a condition where the hemoglobin 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.

33. RISK FACTORS Infants and children Pregnant women Pre menopausal women Adolescent girls Older adults Alcoholism Chronic/ critically ill Excessive exercise CAUSES Inadequate diet Insufficient intake of iron Iron malabsorption Pregnancy Excessive menstrual bleeding Hook worm infestation Malaria Close birth intervals GI bleed

34. CLINICAL MANIFESTATIONS

35. EFFECTS OF ANEMIA Increases risk of maternal and fetal morbidity and mortality Abortions, premature births, PPH, low birth weight are associated with anemia during pregnancy PREGNANCY

36. Anemia can be aggravated by parasitic infections like malaria, intestinal parasites Iron deficiency may repair cellular response and immune functions More severe the anemia, greater the reduction in work performance INFECTION WORK CAPACITY

37. PREVENTION Estimation of Hb to assess degree of anemia Blood transfusion in severe cases of anemia (<8g/ dL ) Iron and folic acid supplements Food fortification with iron Changing dietary habits Control of parasites Nutritional education and awareness

38. IODINE DEFICIENCY DISORDERS (IDD) IDD leads to a much wider spectrum of disorders commencing with the intrauterine life and extending through childhood to adult life with serious health and social implications

39. DISORDERS Goiter Hypothyroidism Subnormal intelligence Delayed motor milestones Mental deficiency Hearing defects Speech defects Mental retardation Neuromuscular weakness Endemic cretinism Intrauterine death

40. PREVENTION Iodized salt Iodine monitoring Public awareness and education COMPLICATIONS Thyrotoxicosis Iodide goiter Iodinism Lymphocytic thyroiditis

41. ENDEMIC FLUOROSIS In many parts of the world where drinking water contains excessive amounts of fluorine (3-5mg/L), endemic fluorosis has been observed.

42. DENTAL FLUOROSIS It occurs when excess fluoride is ingested during the years of tooth calcification – first 7 years of life Characterized by molting of dental enamel which has been reported above 1.5mg/L intake Fluorosis seen on the incisors of upper jaw

43. SKELETAL FLUOROSIS Associated with life time daily intake of 3-6mg/L or more Heavy deposition of fluoride in skeleton Crippling occurs leading to disability

44. PREVENTION Changing the water sources Chemical defluorination Preventing use of fluoridated toothpaste Fluoride supplements not prescribed for children consuming fluoridated water

45. LATHYRISM It is a paralyzing disease of human and animals Also referred to as Neurolathyrism as it affects the nervous system Lathyrus Sativus is commonly known as ‘ khesari dhal’, a good source of protein but its toxins affects the nerves The toxin present in lathyrus seed has been identified as BETA OXALYL AMINO ALANINE (BOAA) which has blood brain barrier

46. STAGES OF LATHYRISM Latent stage No stick stage One stick stage Two stick stage Crawler stage

47. INTERVENTIONS Vitamin C prophylaxis Banning the crop Removal of toxin Education and awareness Genetic approach – producing low toxin variety of crop Socio economic changes

48. NUTRITIONAL PROGRAMS Vitamin A P rophylaxis Program Prophylaxis against Nutritional Anemia IDD Control Program Specific Nutrition Program Balwadi Nutrition Program Integrated Child Development Scheme Mid – day Meal Program Mid – day Meal Scheme

49. CHRONIC DISEASES

50. OBESITY Obesity is an epidemic diseases, which consists of body weight that is in excess of that appropriate for a person’s height and age standardized to account for differences, leading to an increased risk to health related problems

51. Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A crude population measure of obesity is the body mass index (BMI), a person’s weight (in kilograms) divided by the square of his or her height (in metres ). A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.

52. EATING DISORDERS

53. ANOREXIA NERVOSA Anorexia nervosa  is an eating disorder characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure, and an irrational fear of weight gain, as well as a distorted body self-perception.

54. BULIMIA NERVOSA Bulimia nervosa  is an eating disorder characterized by  binge eating and purging, or consuming a large amount of food in a short amount of time followed by an attempt to rid oneself of the food consumed (purging), typically by vomiting, taking a laxative, diuretic, or stimulant, and/or excessive exercise, because of an extensive concern for body weight.

55. CLINICAL MANIFESTATIONS Amenorrhea Obvious, rapid, dramatic  weight loss   at least  15% under normal body weight [ May engage in frequent, strenuous, or compulsive  exercise Perception of self as overweight despite being told by others they are too thin Intolerance to cold and frequent complaints of being cold. Body temperature may lower in an effort to conserve energy Hypotension and/or orthostatic hypotension

56. Bradycardia or tachycardia Depression: may frequently be in a sad, lethargic state Solitude: may avoid friends and family; becomes withdrawn and secretive Swollen joints Abdominal distension Halitosis (from vomiting or starvation-induced ketosis) Dry hair and skin, as well as hair thinning Fatigue Rapid mood swings

57. CONCLUSION Good nutritional habits and a balanced diet aren't developed in one day, nor are they destroyed in one unbalanced meal. Healthful eating means a lifestyle of making choices and decisions, planning, and knowing how to make quick and wise choices when you haven't planned.

58. INTERNET INFORMATION Metformin is a drug commonly used to treat type 2 diabetes. But new research published in the  Proceedings of the National Academy of Sciences (PNAS)  finds the medication may also slow the aging process and increase lifespan.

59. JOURNAL INFORMATION Overweight and obesity among children – TNNMC journal of CHN Nutritional status of pre school children attending balwadi – Indian Journal of nutrition and dietetics

60. BIBLIOGRAPHY Dudek Susan G – Nutrition essentials for nursing practice K Park – Textbook of preventive and social medicine John Sheila – Essentials of nutrition and dietetics for nursing Fraser Diane, Cooper Margaret A – Myles textbook for midwives Swaminathan K – Nutrition and dietetics