Nutritional problems in public health

it is power point presentation for public health denstistry

1. DEPARTMENT OF PUBLIC HEALTH DENTISTRY NUTRITIONAL PROBLEMS IN PUBLIC HEALTH Submitted by Guided by Mayank Chhangani Dr. Gaurav Chhabra Final Year Dr. Daman Gupta Dr. Nikku Nebwani

2. There are many nutritional problems which affect vast segments of our population. The major ones are…..

3. 1. LOW BIRTH WEIGHT A major health problem in many developing countries 30% of children born in India are LBW compared to 4% in developed countries Maternal malnutrition and anemia are significant risk factor for its ocurance Causes include hard physical labor during pregnancy and illness Associated factors are short maternal stature, very young age, high parity, smoking and close birth intervals The proportion of infants born with LBW has been selected as one of the nutritional indicators for monitoring progress towards “Health for All” by the year 2000

4. 2. PROTEIN ENERGY MALNUTRITION Occurs in children in first years of life Important cause of childhood morbidity and mortality Surviving children suffer form physical and mental growth Kwashiorkor and Marasmus are the two different clinical pictures of the disease.

5. The incidence of PEM in India in preschool age children in 1-2%. About 80% of cases of the disease in India go unrecognized. Marasmus is more frequent than Kwashiorkor. The disease is primarily due to: Inadequate intake of food both in quality and quantity Infections like diarrhea, measles and intestinal worms It is a vicious circle: Infection contributing to malnutrition and malnutrition contributing infection, both acting synergistically The first indicator of Protein Energy Malnutrition is underweight for age. To detect this, method employed by a Field Worker is to maintain growth charts. These charts indicate a glance whether child is gaining or losing weight.

6. Malnutrition is self perpetuating . A child’s nutritional status depends upon his or her past nutritional history as shown in the figure:

7. The principle features of Kwashiorkor and Marasmus are:

8. Classification of Protein Energy Malnutrition Gomez’ Classification based on weight retardation locates the child on the basis of his or her weight in comparison with a normal child of the same age this is done as follows: Weight is easily recorded and classification is easy to compute.

9. disadvantages of Gomez’ Classification are cut off point of 90% of reference is high, thus some normal children may be classified as 1 st degree malnourished. by measuring only weight for age, it is difficult to know if the low weight is due to a sudden acute episode of malnutrition or to long standing chronic undernutrition . 2. Waterlow’s Classification When a child’s age is known, measurement of weight enables almost instant monitoring of growth : measurements of height assess the effect of nutritional status of long term growth .

10. Waterlow’s classification defines two groups for PEM malnutrition with retarded growth, in which a drop in the height/age ratio points to a chronic condition-shortness, or stunting: malnutrition with a low weight for a normal height, in which the weight for height ration is indicative of an acute condition of rapid weight loss. This combination of indicators makes it possible to label and classify individuals with reference to two poles: children with insufficient but well proportioned growth, and those with a normal weight, but who are wasted PREVENTIVE MEASURES There is no simple solution to the problem of PEM. The following are adapted from the FAO/WHO Expert Committee on Nutrition for prevention of PEM in the community

11. Health Promotion Measures directed to pregnant and lactating women. Promotion of breast feeding. Development of low cost weaning foods : the child should be made to eat more food at frequent intervals. Nutrition education- promotion of correct feeding practices. Home economics. Measures to improve family diet. Family planning and spacing of births. Family environment. Specific Protection The child’s diet must contain protein and energy-rich foods. Milk, eggs, fresh fruits should be given if possible. Immunization. Food fortification Early Diagnosis and Treatment Periodic surveillance. Early diagnosis of any lag in growth. Early diagnosis and treatment of infections and diarrhoea .

12. Development of programs for early rehydration of children with diarrhea. Development of supplementary feeding programs during epidemics. Deworming of heavily infested children. Rehabilitation Nutritional rehabilitation services. Hospital treatment. Follow-up care. 3. XEROPTHALMIA Also called as “ Dry Eye ” Refers to all the ocular manifestations of vit . A deficiency. Most widespread and serious nutritional disorder, leading to blindness, particularly in South East Asia. Most common in “ children aged 1-3 years” . Younger the child, the more severe the disease

13. It is often associated with Protein Energy Malnutrition. Victims belong to the “ Poorest Families ”. Risk factors include Ignorance, Faulty feeding practices and Infections, particularly Diarrhoea and Measels In India, predominantly “Rice Eating” states are badly affected, notably Southern and Eastern States like Andhra Pradesh, Tamil Nadu, Karnataka, Bihar and West Bengal . Prevention and Control It must an integral part of Primary Health Care. An overall strategy can be defined, according to World Health Organization, in terms of Short-term, Medium Term and Long Term Action.

14. Short Term Action: Administration of large doses of Vitamin A orally, in recommended doses to vulnerable groups, on periodic basis. It can be organized quickly with minimum of infrastructure. It is done as follows:

15. Medium Term Action: Fortification of certain food with Vitamin A is done to promote regular and adequate intake of Vitamin A. Typical example in India is “ addition of Vitamin A to Dalda ” . Other examples are sugar, salt, tea, margarine and dried skimmed milk. Fortifying an appropriate food with Vitamin A is complex process. The greatest challenge to successful fortification programs is choosing a food that is likely to be consumed in sufficient quantities by groups at risk. Long Term Action: These are measures aimed at “ Reduction or elimination of factors contributing to ocular disease. All these are components of Primary Health Care ” Persuading people, particularly mothers, to consume dark green leafy vegetables , or other vitamin A rich foods . Promotion of breast feeding for as long as possible Improvements in environmental health Immunization against infectious diseases such as measles, prompt treatment of diarrhea and other associated infections.

16. Better feeding of infants and children. Improved health services for mothers and children. Social health and education. The Government of India started its National Vitamin A Prophylaxis Program for the prevention of blindness in children in 1970 based on Periodic Massive Dosing of children with 200,000 IU (or 110 mg) of Retinol Palmitate in oil every 6 months. The coverage is being gradually increased. A flexible strategy combining Short, Medium and Long Term Interventions with Nutrition Education has been adopted

17. 4. NUTRITIONAL ANEMIA Defined by WHO as: A condition in which, 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 It established if hemoglobin is below cut off point recommended by WHO. The most frequent cause of Nutritional Anemia is Iron deficiency and less frequently foliate or Vitamin B12.

18. THE PROBLEM In India Major nutrition problem. Many have iron deficiency without anemia. Highest among women and young children (about 60-70%) Foliate deficiency anemia affects 25-50% of pregnant women In World Highest prevalence in developing countries Found in women of child bearing age, young children and during pregnancy and lactation In developing countries, affects about 2/3 rd of pregnant and ½ of un pregnant women. Developed countries are also not completely free from anemia A significant percentage of women of child bearing age are anemic.

19. Detrimental Effects Detrimental effects of anemia can be seen in three important areas Pregnancy Increases the risk of maternal and foetal mortality and morbidity. In India, 20-40% deaths due to anemia. Abortions, premature births, post-partum haemorrhage and low birth weight are associated with lob haemoglobin levels in pregnancy. Infection Due to parasitic e.g. malaria, intestinal parasites Iron deficiency may impair cellular responses and immune functions and increase susceptibility to infection Work Capacity It causes a significant impairment of maximal work capacity The more severe the anemia, the greater the reduction in work performance, and thereby productivity This has great significance in the economy of the country

20. 5. Iodine Deficiency Disorders The world Continues to be major problem in many third world countries It is major health problem of considerable magnitude in India, Bhutan, Bangladesh, Myanmar, Indonesia, Nepal, Sri Lanka and Thailand More people are affected and levels of severity are higher in South East Asia than anywhere else in the world.

21. India In India, goitre is found significantly in Himalayan Goitre Belt , which is biggest goitre belt in the world. It stretches from Kashmir to Naga Hills in the east, extending about 2400km and affecting the northern states of Jammu and Kashmir, Himachal Pradesh, Punjab, Haryana, Delhi, Uttar Pradesh, Bihar, West Bengal, Sikkim, Assam, Arunachal Pradesh, Nagaland, Mizoram, Meghalaya, Tripura and Manipur Outside the Himalayan Goitre Belt, the other areas of India include, parts of Madhya Pradesh, Gujarat, Maharashtra, Andhra Pradesh, Kerala and Tamil Nadu , Bharuch district in Gujarat and Ernakulam district in Kerala No State in India can be said to be entirely free from Goitre More than 140 million people are estimated to be living in goitre belt of India alone, nearly 55 million are estimated to be suffering from endemic goitre

22. Goitre Control There are four essential components of National Goitre Control Programme . These are Iodized Salt, Monitoring and Surveillance, Manpower Training and Mass Communication Iodized Salt Most widely used Prophylactic Public Health Measure against endemic goitre Level of iodization is fixed under the Prevention of Food Adulteration (PFA) Act It is not less than 30ppm at the production point, and not less than 15ppm of iodine at the consumer level Under the National Iodine Deficiency Disorder Control Activities , the Government of India proposed to Completely replace common salt with Iodized Salt in a phased manner by 1992

23. Iodine Monitoring and Surveillance Countries implementing control programmes require a network of laboratories for iodine monitoring and surveillance. These laboratories are essential for idoine excretion determination, determination of iodine in water, soil and food as part of epidemiological studies , and determination of iodine in salt for quality contorl Manpower Training It is vital for the success of control that health workers and others engaged in the programme be fully trained in all aspects of goitre contorl including legal enforcement and public education. Mass Communication It is a powerful tool for nutrition education It should be fully used in goitre control work Creation of public awareness is a sine qua non of a successful publinc health programme

24. Endemic Fluorosis It has been reported where drinking water contains excessive fluorine ( 3-5 mg/L ) It is an important health problem in many parts of the country, including Andhra Pradesh ( Nellore, Nalgonda and Parakassam ), Punjab, Haryana, Kerala, Karnataka and Tamil Nadu Toxic manifestations of Endemic Fluorosis include Dental Fluorosis , Skeletal Fluorosis and Genu Valgum Dental Fluorosis Flourosis of enamel occurs when excess fluoride is ingested during the years of tooth calcification- essentially during the first 7 years of life It is characterized by “mottling” of dental enamel, due to levels above 1.5mg/L intake. Teeth lose their shiny appearance and chalk-white patches develop on them Later white patches become yellow and sometimes brown or black In severe cases loss of enamel gives the teeth a corroded appearance

25. Mottling is best seen on maxillary incisors It is almost confined to permanent and develops only during the period of formation Skeletal Fluorosis Associated with lifetime daily intake of 3.0 to 6.0 mg/L or more Heavy fluoride deposition in the skeleton When a concentration of 10 mg/L is exceeded, crippling fluorosis can ensue. Leads to permanent disability

26. Genu Valgum Form of fluorosis characterised by Genu Valgum and osteoporosis of the lower limb in some districts of Andhra Pradesh and Tamil Nadu Syndrome observed among people whose staple was sorghum ( jowar ) Diets based on sorghum promoted a higher retention of ingested fluorine than do diets based on rice

27. Intervention Changing Water source Find a new source of drinking water with a lower fluoride content ( 0.5 to 0.8 mg/L ) Running surface water contains lower quantities of fluoride than ground sources Chemical Treatment Water can be chemically defluoridated in a water treatment plant Nalgonda Technique of defluoridation of water involves addition of lime and alum is sequence followed by flocculation, sedimentation and filtration Other measures Fluoride supplements should not be prescribed for children who drink fluoridated water. Use of fluoride toothpaste in areas of endemic fluorosis is not recommended for children up to 6 years of age