Malnutrition Disease





 MALNUTRITION 

Malnutrition  has been defined as " a pathological  state resulting  from a relative or absolute deficiency  or excess of one or more essential  nutrients". It  comprises  four forms__ undernutrition, overnutrition, imbalance  and the specific  deficiency. 





(1) Undernutrition : This is the condition which results when insufficient food is eaten over an extended   period of time. In extreme cases, it is called starvation. 

(2)Overnutrition : This is the  pathological state resulting  from the consumption  of excessive  quantity  of food over an extended  period of time. The high incidence of obesity,  atheroma and diabetes  in western societies  is attributed to overnutrition. 

(3) Imbalance  : It is the pathological  state resulting  from a  disproportion among essential  nutrients with or without  the absolute deficiency  of any nutrient. 

(4)Specific  deficiency: It is the pathological state resulting  from  a relative  or absolute  lack of an individual  nutrition.  

 The effects of malnutrition  on the community  are both direct and indirect. The direct effects  are the occurrence  of frank  and subclinical  nutrition deficiency  diseases  such as kwashiorkor, marasmus, vitamin  and  mineral  deficiency  diseases. The indirect effects  are a high morbidity  and morbidity and mortality  among young children  ( nearly  50 per cent of  total  deaths  in the  developing  countries  occur among  children  under 5  years of age  as compared  to less than 5 per cent in developed  countries),  retarded   physical  and mental   growth and development  ( which may be permanent), lowered vitality of the people leading  to lowered productivity  and reduced  life expectancy.  Malnutrition  predisposes  to infection  and  infection  to malnutrition; and  the morbidity  arising  therefrom as a result  of complications  from such infectious diseases as tuberculosis  and gastro _  enteritis is not inconsiderable. The high rate of maternal mortality,  stillbirth  and low birth_ weight  are all associated  with malnutrition.  


  In the more developed  countries  of the world nutritional  problems  are somewhat different . Overnutrition is encountered much more frequently  than undernutrition. The  health hazards from overnutrition  are a high incidence  of obesity,  diabetes,  hypertension, cardiovascular and  renal diseases,  disorders of liver and gall bladder.From this  brief  review,  it is obvious  that the  consequences  of malnutrition  are ominous.  




Ecology  of malnutrition: 

Malnutrition  is a man_ made disease.  It is a disease  of human societies. It begins quite commonly  in the womb and ends in the grave. The great advantage  of looking  at malnutrition as a problem  in human ecology is that it allows for variety  of approaches  towards  prevention.   Jelliffe ( 1966) listed the ecological  factors related  to malnutrition  as follows : conditioning   influences , cultural influences , socio_ economic  factors, food  production  and health and other  services. 


(1) CONDITIONING  INFLUENCE:

Infectious  diseases are an important  conditioning  factor responsible  for malnutrition,  particularly  in small  children.  Diarrhoea, particularly  in small children.  Diarrhoea,  intestinal  parasites, measles, whooping   cough, malaria,  tuberculosis  all contribute  to malnutrition. In fact it is a vicious circle __ infection  contributing  to malnutrition,  and malnutrition causing an otherwise  minor  childhood ailments  to become killers. It has been  shown that where environmental conditions  are poor,  small children  may suffer from some  infection  or  the other  for almost half  of their  first   three  years  of life. The inter _ relationship  between   malnutrition  and infection  has been  well documented.  



(2)  CULTURAL INFLUENCES : 

Lack of  food is not the only cause  of malnutrition.  Too often  there is starvation  in the midst of plenty. People choose  poor  diets when  good  ones are  available  because  of cultural  influences  which vary widely  from country  to  country,  and from region to region. These  may be stated  as follows: 

(a) Food  habits,  customs, beliefs, traditions  and attitudes : Food habits are  among the oldest  and most deeply  entrenched  aspects of any culture . They have deep psychological  roots and are associated  with love, affection, warmth,  self image and social prestige. The family plays an  important  role in shaping  the food habits, and these  habits  are passed from one generation  to another. Most often many of these customs and beliefs  apply to vulnerable  groups, i.e.,  infants, toddlers,  expectant  and lactating  women.  Papaya is avoided  during  pregnancy  because it is believed  to cause abortion . Valuable  foods such as dahls,  leaf  greens rice and fruits are avoided  by the  nursing  mother. There is a widespread  misbelief  that if a pregnant   women eats  more, her baby  will   be  born big  and  delivery  will be difficult. Certain foods  are " forbidden " as  being  harmful  for the child. Then there are certain  beliefs  foods. 




(b) Religion : Religion  has a powerful  influence  on the food  habits of the  people. Hindus do not  eat beef, and Muslims  pork. Some  orthodox  hindus  do not  eat meat, fish,  eggs and certain vegetables  like onion. These  are known as food taboos  which  prevent  people  from  consuming  nutritious  foods  even  when  these are easily available. 

(c) Food  fads : In the selection  of foods, personal likes  and  dislikes play an important part.  These are called " food_ fads". The  food fads may stand  in the way of correcting  nutritional  deficiencies. 

(d) Cooking   practices  :Draining  away  the rice water  at the end  of cooking, prolonged  boiling  in open pans, peeling  of  vegetables,  all influence  the nutritive  value of foods.

(e) Child rearing  practices: These vary widely from  region to region and influence  the nutritional  status of infants  and children. Examples  of thus situation are premature curtailment  of this  situation  are premature  curtailment  of breast _ feeding, the adoption of bottle feeding  and adoption  of commercially  produced refined  foods. 

(f) Miscellaneous  : In some communities, men eat first  eat first  and women eat last and poorly. Consequently, the health of women in  these societies  may be adversely  affected. Chronic  alcoholism  is another factor  which may lead to serious  malnutrition. 



3) SOCIO_ ECONOMIC FACTORS:

Malnutrition  is largely the by_ product of poverty, ignorance, insufficient  education,  lack of knowledge  regarding  the nutritive  value of foods, inadequate  sanitary  environment,  large family  size, etc. These factors bear  most directly  on the quality  of life and are the true determinants of malnutrition  in the society. The speed  with which population  are growing  in many developing  countries is another important  factor to  reckon with. It had made the solution  of the  malnutrition  problem  more difficult. In short, the causes of malnutrition  are built into the  very nature  of society,  in the socio_ economic  and political structures,  both nationally  and internationally. 

4) FOOD PRODUCTION  :

Increased  food production should lead to increased  food consumption. But increased food production will  not solve  the basic problem of hunger and  malnutrition  in much  of the developing world. The main problem  is of  uneven distribution  between  the countries  and within the countries. It is said  that there will be very little malnutrition  in India today  if all the food available  can be equitably  distributed  in accordance with physiological needs. 

5) HEALTH AND OTHER SERVICES:

The health sector can, if properly  organized and given  adequate  resources  can combat malnutrition . Some of the remedial actions that can be taken  up by the health  sector are: 

(1) Nutritional  surveillance  : Nutritional  surveillance  implies the continuous  monitoring  in a community  or area of factors  or conditions  which indicate,  or relate to the nutritional  status of individuals  or groups of people. 

(2) Nutritional rehabilitation:Immediate measures  are required as soon as the malnourished  subjects are located. Children suffering  from  severe  PEM with complications need urgent care, may be in a hospital. Less severely  affected  children can be  treated  on a  domiciliary  basis  or in special nutrition rehabilitation  centres. These centres   should be linked  with health centres . 




(3) Nutrition Supplementation:The target groups  are mothers and children. Supplementary  feeding  is normally  regarded  as a stop_ gap measures  for the. rehabilitation  of  malnourished  children. 

(4) Health education: It is opined that by appropriate  educational action, about 50 per cent  of nutritional  problems  can be  solved. Health education  programmes in nutrition  is often a weak  component.  Its reinforcement  is a key element  in all health services  development . 

Preventive  and social  measures  : 

Since malnutrition  is the  outcome  of several  factors, the problem can be solved only by taking  action simultaneously  at various levels_ family, community,  national  and international levels. It requires a coordinated approach of many disciplines_ nutrition, food technology,  health  administration, health education,  marketing, etc. In short, it calls for  a comprehensive programme of social development of the  entire country.  



ACTION AT THE FAMILY  LEVEL : 

 The principal  target of nutritional  improvement in the community  is the family, and the instrument  for  combatting  malnutrition  at the family  level  is nutrition  education. The promotion of breast  feeding   practices  are  the two areas  where nutrition education  can have a considerable effect.  Action is also  needed  to counter misleading  commercial advertising  with regard to baby foods. Attention should also be focused on the nutritional needs of expectant  and nursing mothers and  children in the family. The shortage of protective foods can be met to some extent by planning a kitchen garden or keeping  poultry. Adequate  nutrition can be obtained  in most countries  with a combination  of locally  available and acceptable foods. Other related activities  at the family level are the " packages " of mother  and child health, family planning  and immunization  services. The community  health workers and the multipurpose  workers are the kind of people  in key  positions  to impart nutrition  education  to the families  in their respective areas. 


Action AT THE COMMUNITY LEVEL  :

Action at the community  level should commence with  the analysis  of the nutrition  problem  in terms of 

(a) The extent, distribution  and types of nutritional  deficiencies;

(b)  The population  groups at risk, 

(c) The  dietary  and non_ dietary  factors contributing  to malnutrition.  

 In many developing  countries such as India, it is usual to start with direct intervention  measures such as supplementary  feeding  programmes, mid__ day school  meals, vitamin A Prophylaxis  programme but these will only provide  palliative,  partial  or  temporary solutions.  The real permanent  solution  can only come from fundamental  measures that will correct the basic  causes  of  malnutrition . This implies, first of all, increasing  the availability of foods  both in important _ making  sure that the people suffering  or at risk of malnutrition  can obtain these foods. The Applied Nutrition Programme  is an attempt  at production  of  various types of protective  foods  by the community  for the community. The Intrgrated Child  Development  Services ( ICDS) Programme makes a concerted and coordinated  effort to deliver a basic  minimum package consisting  of supplementary  nutrition,  immunization, health check__ ups, health  and nutrition education  for the mothers and non_ formal education  for the pre_ school age children.  The target groups are children up to six years,  pregnant and  lactating  women, and other  women  in the age group 15 to 44 years. Significant  improvements  in the overall living  conditions  of the people is also called for at the community  level. This includes  such measures  as health education , improvement  of water supply, control of infectious diseases . In brief , a broad socio_ economic  development  of the entire community  is called for. 

ACTION AT THE NATIONAL LEVEL 

The  burden of improving  the nutritional  status  of the people, by and large, is the responsibility  of the State. Some of the strategies  and approaches  undertaken  at the national  level in India are : 
(1) Rural development  : The nutritional  upliftment of people, especially  in a country  like India, can come about only as part and parcel of an overall  socio_  economic  development  of rural areas. 

(2) Increasing  agricultural  production : The food production  potential  is still greatly under_ utilized. It must keep pace with population  growth.

(3) Stabilization of population: The population  policy in India is related to food and nutrition  policy. The accent now is on birth spacing and a small family norm.

(4) Nutrition  intervention programmes : Several  nutritional  problems of  developing  countries  today can be mitigated,  if not entirely  solved by short_ term programmes. The prevention  and control of endemic  goitre through iodized common  salt; the control of anaemia through distribution  of  iron and folic  acid tablets  to pregnant  and  nursing  mothers, or possibly  through  fortification of common  foods with iron; the  control of nutritional  blindness  through  periodic administration  of massive oral doses of vitamin  A to children  at risk; supplementary  feeding  programmes   for pre_ school children  are examples  of such measures.  These programmes  have a direct impact  on the health and nutritional  status of  particular  segments  of the population. These  programmes alleviate the situation as a  temporary  measure. 

(5) Nutrition _ related  health  activities: Several programmes  within the field of health, seemingly  unrelated  to nutrition, may have   a profound impact on the  nutritional  status. The National Malaria Eradication  Programme, by opening  up vast tracts of land for  cultivation, has  made  an outstanding  contribution to health  and  nutrition. Since malnutrition  is closely related  to infection,  all programmes of immunization  and improvement  of environmental  sanitation  will inevitably  have a beneficial  effect on nutrition. Programmes  of family planning  could  make a major  contribution  to the improvement  of nutritional  status  of mothers  and children. All these programmes may be considered  as alternative approaches  to improving  the nutritional  status of the people,

ACTION AT THE INTERNATIONAL  LEVEL  

Food  and nutrition  are global problems,  just as health  and sickness; and both are inter_ related.  There is considerable  scope for international  cooperation in solving  the  problems of  malnutrition. Several  international  agencies  such as the FAO, UNICEF, WHO, World Bank, UNDP,  and CAR are  working  in close collaboration  helping  the national government  in different  parts of the world  in their  battle against  malnutrition.  

NUTRITION PROGRAMS  IN PUBLIC HEALTH: 

There  are many nutritional problems  which affect vast segments  of our  population. The major  ones  which deserve special mention  are highlighted: 

1) Low  birth weight ( LBW) 

Low  birth weight  (i.e., birth weight less than 2,500 gram  is a major  public  health problem  in many developing  countries.  Although  in many  developing  countries.  Although  we do not  know of all the causes of LBW, maternal malnutrition  and anaemia  appear  to be significant  risk factors  in its  occurrence .Among the other  causes  of LBW  are hard  physical  labour  during   pregnancy,  and illnesses  especially  infections. Short  maternal  stature,  very young  age,  high parity, smoking, close  birth intervals are all associated  factors.  All these factors  are  interrelated. 

 Since  the problem  is multifactorial, there  is no universal  solution.  Interventions have to be cause_ specific. The proportion  of  infants born with LBW has been  selected  as  one  of the  nutritional  indicators.  

2. Protein energy  malnutrition  ( PEW) 

Protein energy  malnutrition  ( PEW) has  been identified   as a major  health  and nutrition  problem  in India. It occurs  particularly  in weaklings  and children  in the first  years  of life. It is not only  an important  cause  of childhood  morbidity  and mortality, but leads  also  to permanent  impairment  of physical  and possibly, of mental  growth of  those who  survive. The current  concept  of PEM is that its clinical  forms_ kwasniewskor and marasmus _ are two different  clinical  pictures at opposite poles of a single  continuum. 

 The incidence  of PEM  in India in  pre_ school age children  is 1_ 2  per cent .The great majority  of cases of PEM, nearly 80 per cent, are the " intermediate" ones, that  is that  mild  and moderate cases which frequently  go unrecognized. The problem  exists in all the  States  and that  nutritional  marasmus is more  frequent  than  kwashiorkor. 

 In  the 1970s, it was widely  held that PEM was due  to protein deficiency. Over  the  years, the concept  of " protein gap" has given place to  the concept  of " food gap". That is, PEM is primarily  due to 

(a) An inadequate  intake of food ( food gap) both in quantity  and quantity ,

(b)  Infections, notably  diarrhoea, respiratory  infections, measles  and  intestinal  worms which increase  requirements for calories,  protein and other nutrients, while  decreasing  their  absorption  and utilization. It  is a viscous circle_ infection  contributing  to  malnutrition  and malnutrition  contributing  to infection,  both  acting  synergistically. 

  There are numerous  other  contributory  factors in the web of causation, viz. poor  environmental  conditions,  large  family  size, poor, maternal health,  failure of  lactation,  premature termination  of breast _ feeding, and  adverse  cultural practices relating  to child  rearing  and weaning  such as the use of over_ diluted cow's  milk and discarding  cooking  water from cereals  and delayed supplementary  feeding. 

Early detection  of PEM :

The first indicators  of PEM is under  weight  for age. The most practical  method  to detect this, which can be employed  even by field health  workers, is to maintain  growth charts. These charts indicate  at  a  glance whether the child  is gaining  or losing  weight.  

 The principal  features  of  kwashiorkor and marasmus  










Screening  for malnutrition:

 There are several techniques  for  identification  of malnourished  children :

(1)  Height and Weight: The best way  to  identify  children  who are malnourished  is to take their height  and weight  regularly _ once a month in the case of children,  and at 3 to 6  months intervals in the case of older children.  The growth chart  or Road_ to_ health card offers a simple  and inexpensive  means of monitoring  child health  and nutritional  status. 

(2) Mid _ arm  Circumference: Another simple  and useful technique  is to measure  the mid_ arm circumference. An arm  circumference  exceeding  13. 5 cm is a sign of  a satisfactory  nutritional  status, between 12.5 and 13.5 cm. It indicates mild _ moderate malnutrition  and below 12.5 cm, severe  malnutrition.  

(3) Clinical  and Laboratory  Examination  : An  examination  of the child from head to foot for signs of malnutrition  ( e.g., protein, vitamin and mineral deficiencies) is another approach  for  detecting  malnutrition. Such examinations  may be supplemented  by laboratory  tests such as estimation  of haemoglobin. 

PREVENTIVE MEASURES 

 There is no simple solution  to the problem of PEM. Many types  of actions are necessary. The following  is adapted from the 8th FAO/ WHO Expert Committee on Nutrition for the prevention  of PEM in the community: 

(a) Health promotion  

(1) Measures  directed  to pregnant  and lactating  women ( education, distribution  of supplements). 

(2) Promotion  of breast _ feeding. 

(3) Development  of low cost weaning  foods: the child should  be made to eat more food at  frequent intervals. 

(4) Measures  to improve family  diet. 

(5) Nutrition education  _ promotion  of correct feeding  practices. 

(6) Home economics 

(7) Family planning  and spacing  of  births.

(8)  Family environment. 

(b) Specific  protection 

(1)  The child's diet must contain  protein and energy _ rich foods. Milk, eggs, fresh fruits should be given if possible.  

(2) Immunization. 

(3) Food fortification. 

(c) Early diagnosis  and treatment  

1) Periodic surveillance.

2) Early diagnosis  of any lag in growth. 

3) Early diagnosis  and treatment  of infections and diarrhoea.

4) Development  of programmes for early rehydration  of children  with diarrhoea.  

5)  Development  of supplementary feeding  programmes during  epidemics. 

6) Deworming  of heavily infested children.  

(d) Rehabilitation  

1) Nutritional rehabilitation  services. 

2) Hospital  treatment. 

3) Follow_ up  care. 

3) Xerophthalmia:

Xerophthalmia  ( dry eye) refers  to all the ocular manifestations  of vitamin  A deficiency  in man. It is the most widespread  and serious  nutritional  disorder  leading to blindness. 

 Xerophthalmia  is most  common  in children  aged 1_ 3 years, and is often related  to  weaning. The younger  the child, the more severe  the disease.  It is often associated  with PEM. Mortality  is often high in this age group. The victims belong to the poorest families, Associated  risk factors  include ignorance,  faulty feeding  practices  and infections particularly  diarrhoea and measles  which often precipitate xerophthalmia. 

Prevention  and control 

 Prevention  and  control  of xerophthalmia  must be an integral  part of primary  health  care. An overall  strategy  can be defined,  according  to WHO,  in terms of short_ term, medium _ term and long_ term action. 


(a)  Short _ term action : A short _ term  prevention  approach  that has already  demonstrated  its efficacy  is the administration  of large doses of vitamin  A orally, in recommended doses to vulnerable  groups, on a periodic  basis. This  can be organized quickly  and with a minimum  of infrastructure. 

  The Government  of India started  its National Vitamin  A Prophylaxis  Programme  for the prevention  of blindness  in children  in 1970 based on periodic massive dosing  of  children with 200,000 I.U. ( or 110 mg) of  retinol palmitate  in oil every 6 months Presently  1,00,000 I.U of vitamin  A is being given to a child at nine months of age and 2,00,000 I.U. thereafter  at six months intervals upto 5 years of age. 

(b)  Medium_ term action: An  approach  widely  used to promote regular and  adequate intake  of  vitamin  A is fortification  of certain  foods with vitamin A. Addition  of vitamin  A to dried  skimmed  milk  and dalda  is  a typical  example .

(c) Long _ term action : These are measures  aimed at reduction  or  elimination  of factors contributing  to ocular disease,  e.g., persuading  people  in general,  and  mothers in  particular,  to consume generously  dark green leafy  vegetables  or other vitamin A rich foods; promotion of  breast  feeding  for as long as possible; improvements  in environmental  health such as ensuring  safe and adequate  water  supply and construction and maintenance  of pit  latrines to prevent  diarrhoea; immunization  against infectious diseases such as  measles, prompt treatment of diarrhoea  and other  associated  infections; better feeding  of infants and young children; improved  health  services  for mothers and children ; social and health education.  All these are components of primary health  care. 


4) Nutritional anaemia  : 

Nutritional  anaemia is  a disease  syndrome  caused by malnutrition  in its widest sense. It has been 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. By far the most frequent  cause  of nutritional  anaemia  is iron deficiency  and less frequently  folate or vitamin  B12. 












Iron deficiency  anaemia  is a major  nutrition  problem  in india and many other developing  countries. In addition, many subjects  have iron deficiency  without anaemia. The incidence  of anaemia is highest  among  women  and young children,  varying  between  60 to 70 per cent. Recent surveys  indicate   that in rural  India anaemia  is much  more widespread  than higherto  believed, even among  men. 


  Iron  deficiency  can arise either due to inadequate  intake or poor  bio_ availability  of dietary  iron or due to  excessive  losses of iron from the body. Although  most habitual  diets contain seemingly  adequate  amounts  of iron, only a small amount  ( less than  4 per cent) is  absorbed. Women  lose a considerable  amount  of iron  especially  during  menstruation. 

Detrimental  effects 

 The  detrimental  effects  of anaemia  can be seen  in three  important  areas: 

(a) Pregnancy  : Anaemia  increases  the risk of maternal and foetal mortality  and morbidity.  In India, about 19 per cent of maternal deaths  were found to be due to anemia. Conditions  such as abortions,  premature  births, post_ partum haemorrhage  and low birth  weight  were especially  associated  with low haemoglobin  levels in pregnancy. 

(b) Infection  : Anaemia  can be caused  or  aggravated  by parasitic , e.g., malaria, intestinal  parasites. Further, iron  deficiency  may impair  cellular  responses and immune  functions and increase susceptibility  to infection. 

(c) Work capacity  : Anaemia ( even when mild) causes a significant  impairment  of maximal  work capacity. The more severe the anaemia,  the greater the reduction  in work performance,  and thereby productivity. This has great significance  on the economy  of the country. 


Interventions 

An estimation  of haemoglobin  should  be done to assess the degree  of anaemia. If the anaemia is "  Severe", (i.e., haemoglobin  is less than 10g/dl) high doses of iron or blood transfusions  may be necessary. It haemoglobin  is between  10_ 12g/dl, the other interventions are : 

1) Iron and folic acid supplementation: 

In order  to  prevent  nutritional  anaemia  among mothers and children (1_12 years), the Govt. of  India sponsored  a National Nutritional  Anaemia  Prophylaxis  Programme during the Fourth Five year Plan. The  Programme  is  based on daily  supplementation with iron and folic  acid tablets  to prevent  mild and moderate  cases of anaemia. The  beneficiaries  are "  at risk" groups viz. pregnant  women,  lactating  mothers  and children under 12 years. 

Eligibility  criteria : These are determined  by the haemoglobin  levels of the patients. If the haemoglobin  is between  10 and 12, daily supplement with iron and  folic  acid  patient  is referred  to the nearest primary  health  centre. 

Dosage :  (a) Mothers : One tablet of iron and folic  acid  containing   100 mg of elemental  iron ( 300 mg of ferrous sulphate)  and 0.5  mg of  folic  acid  should  be given daily. The daily administration  should be continued  until  2 to 3 months after haemoglobin  level  has returned  to normal so that iron stores are replenished.  It is  necessary  that estimation  of haemoglobin is repeated  at 3 _ 4 months intervals. The exact  period of  supplementation  will depend upon the progress of the beneficiary. 

(b) CHILDREN: If  anaemia   is suspected,  a screening  test for anaemia  may be done on infants at  6 months, and 1 and 2 years of age.One tablet  of  iron  and folic acid  containing  20 mg  of elemental  iron (60 mg of ferrous  sulphate) and 0.1 mg of folic acid should  be given daily. 

2) Iron fortification  

The WHO  experts  did not recommend  iron fortification  strategy  for control of anaemia  in regions  where its prevalence  is high. However, recent  studies in India at the National  Institute  of Nutrition,  Hyderabad  showed that simple  addition  of ferric  orthophosphate or ferrous sulphate  with sodium  bisulphate  was enough  to fortify salt with iron. When consumed  over a period of 12 _ 18  months, iron fortified  salt was found to reduce  prevalence  of anaemia  significantly. Fortification  of salt with iron  has been  accepted by the Govt. of India as a public health  approach to reduce prevalence  of anaemia. Commercial  production  of iron fortified  salt started in 1985. 

Iron fortification  has many advantages  over iron supplementation. As salt is a universally  consumed dietary item, all segments of the population stand to benefit.  No special  delivery systems are required. 

(3) Other Strategies  

There are other strategies  such as changing dietary habits, control of parasites and nutrition education. These are long term measures applicable to situations where the prevalence and severity of anaemia are lower: 

5) Iodine  deficiency disorders ( IDD) 

Iodine deficiency is yet another major nutrition problem in India. Previously, iodine deficiency  was equated with goitre. In recent years,  it has become  increasingly  clear that iodine deficiency leads to a much wider spectrum of disorders commencing  with  the intrauterine life and extending  through  childhood  to adult life serious  health  and social implications. The social impact of iodine deficiency arises not so much from goitre as from  the effect on the central  nervous  system. 

The Problem 

The magnitude of the problem in India is very great.  Currently, no less than 170 million  people  are estimated  to be affected  in  the country. In the sub_ Himalayan  goitre belt of india alone, nearly 120 million  are estimated  to be suffering from endemic goitre. In one particular  district ( Gonda) of Uttar Pradesh  known to be highly endemic, the prevalence  of neonatal hypothyroidism  was measured  as  the extremely high rate  of 15 per cent.  





Goitre control 

There are four essential components of national  goitre control  programme. These are iodized  salt or oil, monitoring  and  surveillance, manpower  training  and mass communication.  

1)  Iodized salt : 

The ioduzation of salt  is now the most widely  used prophylactic  public  health measures against  endemic  goitre. Iodized  salt  is most economical, convenient  and effective  means  of mass prophylaxis  in endemic   areas.  Under   the national  IDD control activities, the  Govt. of India proposed to completely  replace  common salt with iodized  salt in a phased manner by the end of 8th plan. With effect   from  17 May 2006, under the Prevention  of Food Adulteration  Act, Ministry of  health  & iodized  salt  for direct human  consumption.  

Iodine monitoring 

Countries  implementing control programmes require a  network  of laboratories for iodine monitoring  and surveillance. These  laboratories  are essential  for  
a) Iodine  excretion  determination 

b) Determination  of  iodine  in water, soil and food as part  of  epidemiological  studies,

(c) Determination of iodine  in salt for quality  control. 

 Neonatal  hypothyroidism is a sensitive  pointer to environmental iodine deficiency and can thus be an  effective  indicator  for monitoring  the impact  of a  programme. 

3. 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  control  including  legal  enforcement  and public education.  

4 . Mass communication  

Mass communication  is a powerful  tool for nutrition  education. It should be fully used in goitre   control  work. Creation  of public awareness  is central issue of a successful public health programme. 


6) Endemic  fluorosis  

In many parts of the  world  where drinking  water contains excess amounts  of fluorine (3_5 mg/L) endemic fluorosis  has been  observed . Endemic  fluorosis has been reported  to be an important  health problem  in certain parts of the country,  e.g., Andhra Pradesh  ( Nellore, Nalgonda and Prakasam  districts),  Punjab,  Haryana, Karnataka,  Kerala and Tamil Nadu.  The toxic manifestation  of fluorosis  comprise the following: 

(a) Dental Fluorosis :Florosis  of  dental  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, which has been reported  at levels  above  1.5 mg/ L intake. The teeth lose their shiny  appearance  and chalk_ white patches  develop  on them. This is the early sign of dental  fluorosis. Later the white  patches  become yellow  and sometimes brown or black. In severe cases, loss  of enamel gives  the teeth a  corroded appearance. Mottling  is best seen on the incisors   of  the  upper jaw. It is almost  develops only during  the period of formation. 

(b) Skeletal  fluorosis: This is  associated  with lifetime  daily intake  of 3.0 to 6.0 mg/ L or more.  There is heavy  fluoride  deposition  in   the skeleton.  When  a concentration  of 10 mg/ L  is exceeded, crippling  fluorosis  can ensue. It leads to permanent  disability. 


(c) Genu  valgum: A new form of fluorosis  characterized  by  genu valgum  and osteoporosis  of the lower limbs  has been reported. 

Intervention 

One solution  to the problem  is to find  a new source of drinking  water with lower  fluoride content. If it is not  possible , the water can be defluoridated  in   a  water  treatment  plant.  Fluoride supplements  should not be prescribed  for children  who drink  fluoridated  water. The use of fluoride  toothpaste  in  areas  of endemic  fluorosis  is not  recommended  for children  upto 6 year of age. 


7) Lathyrism 

Lathyrism   is  a paralyzing  disease  of humans  and  animals. In the humans it is referred  to as neurolathyrism. It is  a crippling  disease  of the nervous  system  characterized  by gradually  developing  spastic paralysis of  lower limbs, occurring  mostly in adults consuming  a pulse, " Lathyrus sativus" in  large quantities. 








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