Protein Energy malnutrition and oral health

1. PROTEIN
ENERGY
MALNUTRITION
AND ORAL
HEALTH
Dr Nayana M
1st year Post Graduate
Department of Public
Health Dentistry
1

2. CONTENT
S• •Introduction
• • Definition of nutrition
• • Malnutrition and types
• • Definition , classification and requirements of protein
• • Protein energy malnutrition
• • Epidemiology
• • Pathophysiology
• • Factors related to malnutrition
• • Web of causation for protein energy malnutrition
• • Classification of protein energy malnutrition
2

3. CONTENT
S• • Protein malnutrition-
 Marasmus
 Kwashiorkor
 Marasmic-kwashiorkor
• •Effects of protein malnutrition on oral health
• • Diagnosis of malnutrition
• • Management
• • Prevention
• Nutritional programmes
• • Conclusion
• • References
3

4. Introduction
• Nutrition is the intake of food, considered in relation to the body’s dietary needs
• An adequate, well balanced diet combined with regular physical activity – is a
cornerstone of good health
• Poor nutrition can lead to reduced immunity, increased susceptibility to disease,
impaired physical and mental development, and reduced productivity
• Food is the best source of all the nutrients
• Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of
energy and/or nutrients
4

5. Nutrition
• Definition by WHO - Nutrition is the intake of food, considered in relation to the
body’s dietary needs
• The concept of metabolism, the transfer of food and oxygen into heat and
water in the body, creating energy, was discovered in 1770 by Antoine Lavoisier,
the “Father of Nutrition and Chemistry.”
• Nutrients are chemical compounds in food that are used by the body to
function properly and maintain health
• They are divided into macronutrients and micronutrients according to the
quantities of their consumption
5

6. Nutrients
6

7. Malnutrition
• Malnutrition(WHO) refers to a cellular imbalance between supply of nutrients and energy and
the body's demand for them to ensure growth, maintenance, and specific functions.
• The term malnutrition covers 2 broad groups of conditions:
Under nutrition
Overweight
• Under nutrition includes stunting/chronic malnutrition(low height for age),wasting/acute
malnutrition(low weight for height),underweight(low weight for age)and micronutrient
deficiencies or insufficiency(a lack of important vitamins and minerals)
• Overweight, obesity and diet-related non communicable diseases (such as heart disease,
stroke, diabetes and cancer)
7

8. 8

9. Source :Global Nutrition report 2018, WHO 9

10. Malnutrition
Source: UNICEF Data of Malnutrition
10

11. PROTEINS
• Any of a group of complex organic macromolecules that contain carbon, hydrogen, oxygen,
nitrogen and usually sulfur and are composed of one or more chains of amino acids.
RDA by Indian Council
Of Medical Research
11

12. Roles of Protein in the Body
• Structural : Collagen- matrix protein of skin, bones and teeth,
Crystallin-structural protein of eye lens
• Transport and binding : Hemoglobin for oxygen transport ,
Ferritin- iron storage
• Enzymes : Salivary amylase – catalyzes the breakdown of
starch to sugar in the mouth , Pepsin- digests protein in the
stomach
• Regulation : Insulin- hormone that regulates uptake and
storage of glucose , Calmodulin- involved in the regulation of
calcium mediated processes
• Protection : IgA- antibodies in saliva , Histatins- salivary
antibacterial proteins
• pH regulation : Sialin- Salivary pH buffering protein
• Protein conjugates : Glycoproteins, Lipoproteins (LDL),
Nucleoproteins(chromatin, nucleosomes)
12

13. CLASSIFICATION OF PROTEINS
I. Based on chemical nature and solubility
Simple
Conjugated
Derived
Globular proteins
Scleroproteins
Primary
Secondary
13

14. II. Based on function III. Nutritional Classification
• Structural proteins Complete proteins like egg albumin,
• Enzymes milk casein
• Transport proteins Partially incomplete proteins
• Hormonal proteins like wheat , rice proteins
• Contractile proteins Incomplete proteins like gelatin
• Storage proteins
• Genetic proteins
14

15. Digestion & Absorption of Proteins
15

16. Composition of Proteins
Major elements are :
• Carbon -50-55%
• Oxygen- 19-24%
• Nitrogen-13-19%
• Hydrogen- 6-7.3%
• Sulfur- 0-4%
Minor elements are:
• Phosphorous
• Iron
• Copper
• Magnesium
• Zinc
16

17. Protein Energy Malnutrition
• Under nutrition is identified as a major health and nutrition problem in India
• Its 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
• In 1970s, it was widely held that PEM was due to protein deficiency
• Over the years ,the concept of “protein gap” has given place to food gap
• That is PEM is primarily due to a) an inadequate intake of food both in quantity
and quality (food gap) and b)infections, notably diarrhea ,respiratory infections ,
measles and intestinal worms which increase requirements for calories , proteins
and other nutrients while decreasing their absorption and utilization
17

18. Direct and Indirect Causes of malnutrition
Source: Canadian
Medical Association
Journal
18

19. Malnutrition /Infection cycle
19

20. Pathophysiology of PEM
Source : Canadian Medical
Association Journal
20

21. Contributing factors
• Poor environmental conditions
• Large family size
• Poor maternal health
• Failure of lactation
• Premature termination of breast feeding
• Adverse cultural practices relating to child rearing and child weaning such as use of over
diluted cow’s milk and discarding cooking water from cereals and delayed supplementary
feeding
• A child’s nutritional status at any point of time depends on his or her past nutritional history
• To an extent nutritional history is linked to mother’s health and nutritional status .This in turn is
influenced by her living conditions and nutritional history during her own childhood
21

22. Nutritional status of woman of child
bearing age
Nutritional status of
pregnant woman
Nutritional status of lactating
women
Nutritional status at puberty
Girl’s nutritional status
Neonatal and infant nutritional
status
22

23. Framework of causes of maternal and child malnutrition
23

24. Classification of PEM
24

25. Types of PEM
Kwashiorkor
Marasmus
Marasmic-Kwashiorkor
25

26. Kwashiorkor
• Acute form of PEM , develops from a sudden and recent food
deprivation.
• Most common in children between ages of 18 and 24 months
• The term ‘Kwashiorkor’ derives from a Ghanaian term which
reflects the effects of weaning of a first child at the time
second child is born(disease of the deposed child)
• Hence it develops when the child is weaned to a low nutrient
diet from a complete nutrition provided by breast milk
26

27. Etiology & Precipitating factor
• Dietary inadequacy : Deficiency of indispensable amino acids for the growing child when there is
a transition from a completely nutritious breast milk to a low nutrient diet
• Precipitation factors
Result of an acute infection like diarrhea or measles or any weakened condition that changes
the nutritional needs of the child
Anorexia seen in infections
 Bad habit of withholding food in mouth in measles and diarrhea up to the level of starvation
Aflatoxin poisoning also leads to Kwashiorkor as it damages the DNA
27

28. Manifestations of Kwashiorkor
• Growth retardation
• Edema which starts in the feet and lower leg region which then generalizes
Edema will be soft and pitting affecting back , dorsum of feet and hands
Cheeks become bulky ,pale and waxy in appearance (moon face)
• Muscle wasting
Generalized muscle wasting- preservation of subcutaneous fat
Children are often weak , hypotonic and unable to walk
• Psychomotor changes
Marked apathy, lack interest in the surrounding
Look sad and never smile , with little movements
Cry is weak
28

29. Other Manifestations
• Skin & hair changes : Rash appears mainly in areas of increased pigmentation.
These pigmented areas subsequently desquamate leaving atrophic, hypo
pigmented and easily damage skin or even ulcerations
Hair colour and texture changes
Seen in back of thighs and in axillae
Petechiae seen over the abdomen
• Hepatomegaly : Due to fatty infiltration of liver
• Anemia : Deficiency of protein , iron , zinc , copper
Also infections causing disruption in iron metabolism
• Poor resistance to infections
29

30. Oral manifestations
• Bright reddening of tongue
• Loss of papillae: erythematous and smooth dorsum of tongue
• Kwashiorkor:
Edema of tongue with scalloping around the lateral margins due to indentation of the
teeth
• Bilateral angular cheilosis
• Fissuring of lip
• Loss of circumoral pigmentation
• Dry mouth
Reduced caries activity due to lack of substrate carbohydrate.
• Decreased overall growth of jaws
• Delayed eruption
• Deciduous teeth may show hypoplasia
30

31. Laboratory findings
1. Total plasma protein (less than 4 gm/dl).
2. Serum albumin (less than 2 gm/dl).
3. Urea in blood and urine is markedly reduced because of deficient intake of exogenous
protein.
4. Total body sodium is higher than normal. Serum sodium may be low due to the excessive
amount of water extracellular fluid compartment.
5. Low total body potassium due to potassium losses by diarrhea
31

32. Marasmus
• Chronic form of PEM resulting from long term protein-energy
deficits
• Most often seen in children who have had insufficient food
over a long time, commonly in 6-18 months
• Represents not only inadequate calorie intake but also
inadequate protein, indispensable fatty acids, vitamins,
minerals
• Children may not be receiving adequate mother’s milk and
often may subsist on liquid diets, deficient in nutrients
required for growth and even for minimal sustenance
32

33. Etiology
• The specific cause may be:
1. Poor feeding habits
2. A physical defect e.g. cleft lip or cleft palate , which prevent the infant from taking an adequate
diet
3. Diseases, which interfere with the assimilation of food e.g. cystic fibrosis
4. Infections, which produce anorexia
5. Loss of food through vomiting and diarrhea
6. Emotional problems e.g. disturbed mother- child relationship
33

34. Signs & Symptoms
• Muscle weakening including heart muscle
• Impairment of brain and nervous system development ultimately leading to a reduction in
cognitive ability
• Child often appears to be old and shriveled
• The child looks appallingly thin and limbs appear as skin and bone
• Wrinkled skin
• Bony prominence
• Irritability, fretfulness and apathy
• Frequent watery diarrhea and acid stools
• Dehydration
• Edema and fatty infiltration are absent
34

35. Laboratory findings
1. Plasma protein may be normal or slightly lowered. This is because marasmic infants live on their
own muscle protein
2. Blood urea is low since the protein utilized by the infant is totally endogenous protein
3. Blood glucose level is low due to deficient glycogen stores in the liver
35

36. Marasmus v/s Kwashiorkor
36

37. Marasmic-Kwashiorkor
• A severely malnourished child with features of both marasmus and
Kwashiorkor
 The features of Kwashiorkor are
• severe edema of feet and legs and also hands, lower arms, abdomen
and face.
• pale skin and hair, and the child is unhappy.
 There are also signs of marasmus,
• wasting of the muscles of the upper
• arms, shoulders and chest so that you can see the ribs
37

38. Complications of PEM
PEM
Dehydration
and diarrhea Hypothermia
Hypoglycemia
Infections
Congestive
cardiac failure
Vitamin and
other nutrients
deficiency
Electrolyte
imbalance
38

39. Alterations in the organ systems
1.Endocrine System
• The main hormones affected are the thyroid hormones, insulin, and growth hormone
• Changes include reduced levels of tri-iodothyroxine (T3), insulin, insulin-like growth factor-1
(IGF-1), and raised levels of growth hormone and cortisol
• Glucose levels are often initially low, with depletion of glycogen stores
• Patients frequently also develop some degree of glucose intolerance of unclear etiology and
are at risk of profound hypoglycemia during the re nourishment phase
2.Immune System
• Cellular immunity is affected most because of atrophy of the thymus, lymph nodes, and tonsils
• Changes include reduced CD4 but relatively preserved CD8-T lymphocytes, loss of delayed
hypersensitivity, impaired phagocytosis, and reduced secretory immunoglobulin A (IgA)
• These changes increase the susceptibility of malnourished children to invasive infections
39

40. 3. Gastrointestinal System
• Villous atrophy with resultant loss of disaccharides, and altered intestinal permeability results in
malabsorption, but losses often rapidly recover once nutrition is improved
• Bacterial overgrowth is common with reduced gastric acid secretion
• Pancreatic atrophy is also common and results in fat malabsorption
• Although fatty infiltration of the liver is common, synthetic function usually is preserved
• Protein synthesis, gluconeogenesis, and drug metabolism are decreased
4. Cardiovascular System
• Cardiac myofibrils are thinned with impaired contractility
• Cardiac output is reduced
• Bradycardia and hypotension are also common in the severely affected
• Intravascular volume frequently is decreased
• The combination of bradycardia, impaired cardiac contractility, and electrolyte imbalances
predispose these children to arrhythmias
40

41. 5. Respiratory
• Reduced thoracic muscle mass, decreased metabolic rate, and electrolyte imbalances
(hypokalemia and hypophosphatemia) may result in decreased minute ventilation, leading to
impaired ventilatory response to hypoxia
6. Neurologic
• Specific neurodevelopmental sequelae attributable to just PEM are difficult to ascertain, as PEM
frequently coexists with other nutritional deficiencies
• Malnutrition has been recognized to cause reductions in the numbers of neurons, synapses,
dendritic arborizations, and myelinations, all of which result in decreased brain size
• The cerebral cortex is thinned and brain growth slowed
• Delays in global function, motor function, and memory have been associated with PEM, with
neonates and infants being most susceptible despite the plasticity of the infant’s brain
41

42. 7. Hematological
• Normochromic anemia is often present but can be exacerbated by other nutrient (iron and
deficiencies and infections such as malaria or other parasitic infections
• Blood clotting usually is preserved
42

43. Effects on oral health
1. On Salivary gland
• Normal functioning of the salivary glands is necessary for a healthy oral cavity
• Hypo functioning of the salivary glands has been reported with PEM, which results in a
decreased salivary flow rate, a decreased buffering capacity, and decreased salivary constituents,
particularly proteins
• PEM and vitamin A deficiency are associated with salivary gland atrophy, which subsequently
reduces the defense capacity of the oral cavity against infection and its ability to buffer the
plaque acids
43

44. 2. Effects on jaws and teeth
• The tooth defects of interest are the external structural defects (hypoplasia) that can provide a
more cariogenic environmental niche and less protective enamel and defects that include
mineralization, which might increase the susceptibility to demineralization
• A delayed exfoliation of the primary teeth and a delayed eruption of the permanent teeth
associated with early childhood PEM
• Mothers who had a poor protein diet during pregnancy had infants with retarded
development of bone and teeth
3.Effect on the periodontal status
• Early Childhood Protein-Energy Malnutrition (ECPEM) was related to a worsened periodontal
status in the permanent dentition during adolescence
• ECPEM is likely to affect the developing immune system, a person’s ability to respond to the
colonization with the periodontal pathogens may be adversely affected permanently
44

45. Diagnosis of malnutrition
• A proper diet history
• Anthropometric measurements:
Weight
Height/Length
Mid upper arm circumference
Head circumference
Chest circumference
45

46. Mid upper arm circumference
46

47. Checking for edema
47

48. Management
WHO developed guidelines for management:
oPhase 1: Resuscitate and Stabilize
oPhase 2: Nutritional Rehabilitation
oPhase 3: Follow-up and Recurrence Prevention
48

49. Phase 1:Resuscitate and Stabilize
• The main aim during this phase is to resuscitate, rehydrate, treat infections, prevent sepsis, and
monitor closely to avoid developing complications of treatment
• Patients are most vulnerable during this period, which usually lasts about 1 week
• Feeding should be instituted carefully and slowly, with restriction of caloric intake to avoid
refeeding syndrome
• Continuous nasogastric feeding or small frequent meals including at night may be necessary to
avoid hypoglycemia
• Vitamins, especially thiamine and oral phosphate, also are administered, in addition to
supplemental feeds to prevent the potentially fatal hypophosphatemia with refeeding
• During this phase, patients also should be kept warm, as they are often hypothermic and may
need restriction of physical activities because of decreased cardiac output
• Antibiotics additionally may be necessary even in the absence of fever if infection is suspected
49

50. Phase 2:Nutritional Rehabilitation
• The rehabilitation phase starts once acute complications have been addressed adequately with
gradual return of appetite, resolution of diarrhea and sepsis, and correction of electrolyte
imbalances
• The main goals of this phase are to increase dietary caloric intake, treat occult infections,
complete vaccination, improve family involvement, and stimulate psychomotor activity
• Weight loss is common initially in children with kwashiorkor as their edema resolves
• This phase usually lasts between 2 to 6 weeks
• Elemental iron 2 to 6 mg/kg should be prescribed for 3 months
50

51. Phase 3:Follow-up and Recurrence Prevention
• Discharge planning and follow-up are recommended, as these patients have tendency to
relapse
• Include preventing undernourishment by promoting breast-feeding, complementary and
supplemental feeding, zinc and vitamin A supplementation, universal salt iodization, and hand
washing and other hygiene measures
51

52. TREAT/PREVENT HYPOGLYCEMIA
• Hypoglycemia and hypothermia usually occur together and are signs of infection
• If the child is conscious and blood glucose is <3mmol/l or 54mg/dl:
• 50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded teaspoon of sugar in 3.5
tablespoons water) is given orally or by nasogastric (NG) tube. The starter diet F-75 (see Step 7)
is given every 30 min for two hours (giving one quarter of the two-hourly feed each time).
Thereafter, two-hourly feeds are continued for first 24–48 hours
• If the child is unconscious, lethargic or convulsing:
• sterile 10% glucose (5 ml/kg) is given intravenously (IV), followed by 50 ml of 10% glucose or
sucrose by Naso gastric tube.
52

53. TREAT/PREVENT HYPOTHERMIA
• If the axillary temperature is <35.0°C or the rectal temperature is <35.5°C, the child is given
feeds and re-warmed by covering with a warm blanket or placing the child on the mother’s bare
chest (skin-to-skin) and covering them with a blanket
• A heater or lamp may be placed nearby
• The child must be kept dry and away from drafts
53

54. TREAT/PREVENT DEHYDRATION
• All children with watery diarrhea should be assumed to have
dehydration and given ReSoMal, a special rehydration solution
• It contains less sodium and more potassium and glucose than the
standard oral rehydration solution (ORS)
• If diarrhea is severe, then the standard hypo-osmolar WHO-ORS
(75 mmol sodium/l) may be used as loss of sodium in stool is high
and symptomatic hyponatremia can occur with ReSoMal
• Return of tears, moist mouth, eyes and fontanelle appearing less
sunken, and improved skin turgor are signs that rehydration is
proceeding
• Signs of over-hydration are increasing respiratory rate and pulse
rate, increasing edema and puffy eyelids. If these signs occur,
fluids are stopped immediately and the child reassessed after one
hour.
54

55. CORRECT ELECTROLYTE IMBALANCE
• All severely malnourished children have excess body sodium, even though serum sodium may be low.
• Deficiencies of potassium and magnesium are also present and may take at least two weeks to correct
• Edema is partly caused by these imbalances and must never be treated with a diuretic
• Extra potassium 3–4 mmol/kg/day
• Extra magnesium 0.4–0.6 mmol/kg/day
• The extra potassium and magnesium are not required if electrolyte/mineral solution is used in preparing
ReSoMal
55

56. TREAT INFECTION
• Usual signs of infection, such as fever, are often absent. Therefore, broad-spectrum antibiotics
based on local antimicrobial resistance patterns are given routinely on admission
• If the child appears to have no complications:
 Oral amoxicillin 15 mg/kg eight-hourly for five days
• If the child appears sick or lethargic, or has complications (hypoglycemia, hypothermia, skin
lesions, respiratory tract or urinary tract infection)
 Ampicillin 50 mg/kg intramuscularly (IM)/IV six-hourly for two days, then oral amoxicillin 15
mg/kg eight-hourly for five days
 Gentamicin 7.5 mg/kg IM/IV once daily for seven days
• If the child fails to improve clinically by 48 hours or deteriorates after 24 hours, a third-
generation cephalosporin (e.g. ceftriaxone 50–75 mg/kg/day IV or IM once daily may be started
with gentamicin)
• Anti-malarial treatment is provided if the child has a peripheral blood film positive for malaria
parasites
56

57. CORRECT MICRONUTRIENT DEFICIENCIES
• Children will have vitamin and mineral deficiencies
• Although anemia is common, iron is not given until the child has a good appetite and starts
gaining weight (usually by the second week)
• The following micronutrients are provided daily for the entire period of nutritional rehabilitation
(at least four weeks):
 multivitamin supplements
 folic acid 1 mg/day (5 mg on day 1)
 zinc 2 mg/kg/day
copper 0.3 mg/kg/day
 iron 3 mg/kg/day, but only when gaining weight
57

58. START CAUTIOUS FEEDING
• A cautious approach is required because
of the child’s fragile physiologic state and
reduced capacity to handle large feeds
• Feeding should be started as soon as
possible
• The WHO-recommended starter formula,
F-75, contains 75 kcal/100 ml and 0.9 g
protein/100 ml
• Very weak children may be fed by spoon,
dropper or syringe. Breastfeeding is
encouraged between the feeds of F-75
58

59. ACHIEVE CATCH-UP GROWTH
• Feeding is gradually increased to achieve a rapid weight gain of >10 g gain/kg/day
• The recommended milk-based F-100 contains 100 kcal and 2.9 g protein/ 100 ml
• Modified porridges or modified family foods can be used provided they have comparable
energy and protein concentrations
• A gradual transition is recommended to avoid the risk of heart failure, which can occur if
children suddenly consume huge amounts
• Replace F-75 with the same amount of catch-up formula F-100 every 4 hours for 48 hours
• If weight gain is:
poor (<5 g/kg/day): the child requires full reassessment for other underlying illnesses, for
example tuberculosis (TB);
moderate (5–10 g/kg/day): check whether intake targets are being met or if infection has been
overlooked;
 good (>10 g/kg/day)
59

60. F100 Feeds
60

61. PROVIDE SENSORY STIMULATION AND EMOTIONAL
SUPPORT
• There is delayed mental and behavioral development
• Just giving diets will improve physical growth, but mental development will remain impaired
• This is improved by providing tender loving care and a cheerful, stimulating environment
61

62. PREPARE FOR FOLLOW-UP AFTER RECOVERY
• At this point, the child is still likely to have a low weight-for-age because of stunting
• Good feeding practices and sensory stimulation should be continued at home
• Parents or care givers should be counseled on:
Feeding energy- and nutrient-dense foods;
Providing structured playtimes for the children;
Bringing the child back for regular follow-up checks;
Ensuring that booster immunizations are given;
Ensuring that vitamin A and anti-helminthic drugs are given every six months
62

63. Preventive & Social measures
• Since malnutrition is an outcome of several factors , the problem can be solved only by taking
action simultaneously at various levels:
oAction at the family level
oAction at the community level
oAction at the national level
oAction at international level
63

64. At the family level
• The principal target of nutritional improvement in the community is
family, and the instrument for combating malnutrition at the family
level is nutrition education
• Both husband and wife need to be educated on the selection of
right kinds of local foods and in the planning of nutritionally
adequate diets within the limits of their purchasing power
• The promotion of breast feeding and improvement in infant and
child feeding practices are the two main areas where education can
be given
• Actions to counter misleading commercials regarding baby foods
• Focus should also be on nutritional needs of expectant and nursing
mothers and children in the family
• The community health workers and the multipurpose workers are
the kind of people in key positions to impart nutrition education to
families in their region
64

65. At the community level
• Should commence with analysis of nutrition problem in terms of the extent ,distribution and types of
nutritional deficiencies ,the population & groups at risk and the dietary and non dietary factors
contributing to malnutrition
• By doing diet and nutrition surveys using standardized methods ,planning realistic and feasible
approaches to control the problem
• In India, its usual to start with direct interventions such as supplementary feeding programme , mid
day school meals, Vitamin A prophylaxis programme etc
• Fundamental measures for a permanent solution like increasing the availability of food in quantity and
quality making sure that the needy obtain these foods
• The Applied Nutrition Programme is an attempt at the production of various types of foods by the
community for the community
• The Integrated Child Development Services Programme is a concreted 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 preschool kids
• Over all improvement in the community as health education, improved water supply, control of
infectious diseases i.e.: broad socio economic development of the community
65

66. At the National Level
• Rural development : Nutritional uplift and over all socioeconomic development of rural areas
where 72% of population reside
• Increasing agricultural production: Must be kept in pace with the population growth by
application of modern farming practices , expansion of cultivated areas, the use of fertilizers ,
better seeds etc.
• Effective food distribution system by implying marketing, land tenure and food price policies
• Stabilization of population: The accent now is birth spacing and a small family norm
• Nutrition intervention programmes : Have a direct impact on the health and nutritional status of
particular segments of population and can alleviate the situation as a temporary measure
• Nutrition related health activities : Since malnutrition is closely related to infection , all
programmes of immunization and improvement of environmental sanitation will inevitably have
a beneficial effect on nutrition
66

67. At the International Level
• There is considerable scope for international cooperation in solving problems of malnutrition
• The establishment of World Food Programme in 1963 to stimulate and promote economic and
social development as a means of providing enough safe food to those in need and to come to
the aid of victims of emergency is an example
• FAO, UNICEF, WHO, World bank , UNDP, CARE are working in close collaboration helping the
national governments in different parts of the world in their battle against malnutrition
67

68. Related Programmes
1. Public distribution system
• Launched in June 1947
• Major commodities distributed include staple food grains, such
as wheat, rice, sugar and kerosene, through a network of fair price shops (also known as ration
shops) established in several states across the country to the needs of the poor
• Food Corporation of India, a Government-owned corporation, procures and maintains the PDS
making available food grains at affordable prices
2. Employment generation schemes
• Improves purchasing power through self and wage employment
• The National Food for Work Programme(NFWP) was launched in 2004
• Food grains should be distributed at the work site or if the workers belong to the same
habitation, they can be distributed in the habitation
68

69. Nutrition Programmes in India
69

70. National programmes
1. Integrated Child Development Service Programme (ICDS)(1975)
• This is a unique programme under which a package of integrated services
consisting of supplementary nutrition, immunization, health check up,
referal and education service are provided to the most vulnerable groups
even within children and women, i.e. children up 6 years of age and
expectant/nursing mother, through a common focal point called Anganwadi
(the courtyard centers) in each of the village/urban slums
• to improve the nutritional and health status of children in the age group 0-
6 years;
• - to lay the foundation for proper psychological, physical and social
development of the child;
• - to reduce the incidence of mortality, morbidity, malnutrition and school
drop out;
• - to regulate effective coordination of policy and programme
implementation amongst various departments to promote child
development;
• - to enhance the capability of the mother through proper nutrition
education for taking care of the normal health and nutritional needs and
health of the child
70

71. 2.Special Nutrition Programme (SNP)
• This programme was launched way back in 1970-71 for the same target group as in ICDS i.e.
children below 6 years age and expectant and nursing mothers by the Ministry of Social
Welfare
• The programme is confined to tribal areas and slums
• Main activity under this programme is to provide supplementary feeding to the beneficiaries
for 300 days in a year
• Under this programme, every child is to receive 300 calories and 8 to 15 gms of protein and
every expectant and nursing mother 500 calories and 20 to 25 gms of protein per day
71

72. 3.Balwadi Nutrition Programme
• Bal (children) wadi (home or centre) Nutrition
Programme is a contemporary of SNP and is being
implemented since 1970-71 by the Central Social
Welfare Board and national level nongovernmental
voluntary organizations, namely, Indian Council for
Child Welfare, Harijan Sevak Sangh , Bhartiya
Adimjati (Scheduled Tribe) Sevak Sangh and Kasturba
National Memorial Trust
• This segment of nutrition programme is thus
implemented essentially by non-governmental
organizations
• The beneficiaries of SNP are basically from the
disadvantaged section of the society like
tribal/scheduled caste people, urban slum dwellers and
also migrant labourers
• Children in the age group 3-5 years are covered under
the programme but are being phased out due to
universalization of ICDS 72

73. 4. Wheat Based Supplementary Nutrition Programme
• The scheme was started with the twin objective of providing supplementary nutrition to children and
popularizing wheat intake
• Min of Food places at the disposal of the Department of Women and child Development about 100
thousand tonnes of wheat from the central reserves annually and that Department, in turn, sub-allocates
this wheat among States which utilize the wheat mostly to produce wheat based ready-to-eat nutrition
supplements
• With the spread of ICDS, this wheat or its products are increasingly being utilized for distribution of
supplementary nutrition
• The wheat is supplied to the State Governments by the Food Corporation of India at the same subsidized
rates as for the public distribution system
73

74. Mid day meal Program
• Also known as School Lunch Programme is in operation since 1961
• The major objective is to attract more children for admission to schools and retain them so that
literacy improvement of children could be brought about
Model Menu
74

75. Mid day meal scheme
• Was launched as a Centrally Sponsored Scheme on 15th August 1995
• In 2001 MDMS became a cooked Mid Day Meal Scheme under which every
child in every Government and Government aided primary school was to be
served a prepared Mid Day Meal with a minimum content of 300 calories of
energy and 8-12 gram protein per day for a minimum of 200 days
• The Scheme was further extended in 2002 to cover not only children studying
in Government, Government aided and local body schools, but also children
studying in Education Guarantee Scheme (EGS) and Alternative & Innovative
Education (AIE) centres
• The nutritional norm was revised to 450 Calories and 12 gram of protein in
2006
• In October 2007, the Scheme was extended to cover children of upper
primary classes (i.e. class VI to VIII) studying in 3,479 Educationally Backwards
Blocks (EBBs) and the name of the Scheme was changed from ‘National
Programme of Nutritional Support to Primary Education’ to ‘National
Programme of Mid Day Meal in Schools
• The Scheme was further revised in April 2008 to extend the scheme to
recognized as well as unrecognized Madrasas / Maqtabs
75

76. Other programmes
1. World Food Programme Project
• World Food Programme-UN provides food-stuffs so that supplementary nutrition could be
provided through the projects supported by them
• The WFP provides Soya Fortified Bulger Wheat, Corn Soya Blend and edible oil to benefit
about 2.1 million pre-school children, expectant and nursing mothers
• WFP obtains wheat or rice locally from the Food Corporation of India in exchange for the
butter oil it gets as donation from some European countries
76

77. 2. UNICEF Assistance for Women and Children
• UNICEF's assistance covers a wide spectrum and is available in the sectors of health, education,
nutrition, water and sanitation, rural development urban basic services etc.
• Of course, the focus of all its programmes is essentially on children and also on women, with the
ultimate objective of better child health survival & development
77

78. 3. CARE Assisted Nutrition Programmes
• Under the Indo-CARE Agreement of 1950, CARE-India
extends food aid so that supplementary nutrition can
be provided to pre-school children of age less than six
years and expectant/nursing mothers.
• The CARE assistance is now dovetailed with ICDS
projects and some of the ICDS projects utilize this
assistance for the nutrition component of the
programme.
• The programme covers ICDS projects in 10 States of
the Indian Union. CARE has also monetized oil
received by it as donation for generating funds worth
Rs. 100 million for implementing activities supportive
of ICDS programme
78

79. Further interventions
INTERVENTIONS IN THE HEALTH SECTOR
• With 2.4% of the world land area, India supports 16% of the world's population
• Population control, therefore, remains a key to the resolution of not only food and nutrition
security in India, but almost all the problems that the country faces
• The ultimate objective of all socio-economic development is to bring about a meaningful and
sustained improvement in the well being and welfare of the people and there is no better index
of the well being of people than the state of their health
• The importance of the status of the health of people can, therefore, scarcely be over
emphasized
• Whether directly or indirectly, all health programmes are as important in combating
malnutrition as programme that make available purchasing power, food grains at the subsidized
prices and supplementary nutrition to children and mothers
79

80. • The Health and Family Welfare Ministry also provides maternal and child health services as an
important part of the total health care
• These services include immunization of infants, children and expectant mothers; prophylaxis
programmes to combat nutritional anaemia and Vitamin A deficiency induced blindness; goiter
control programme through production and distribution of iodised salt; popularisation of oral
rehydration therapy against diarrhoea; control programme for various diseases ranging from
Malaria to AIDS etc
• Some of the social initiatives that have a bearing on health are also taken-such initiatives include
increase in the minimum age for marriage, social marketing of contraceptives etc.
80

81. INTERVENTION IN EDUCATION SECTOR
• It has now been well demonstrated, including the example of Kerala State , that higher
educational attainments in a society have a positive influence on health and nutritional status of
the people
• The education also helps in economic development, which in turn improves food and nutrition
security and ultimately improves the quality of life of all people
• Female literacy is still more important because "empirical evidence in Indian context has shown a
high negative correlation between female illiteracy on the one hand and fertility and infant and
maternal mortality on the other
81

82. Conclusion
• India stands at a very vulnerable position with one of the highest prevalence of under nutrition in the
world in spite of improvement in food availability and poverty alleviation
• Malnutrition is an impediment to development, and its presence indicates that basic physiological
needs have not been met
• What is observed as malnutrition is not only the result of insufficient or inappropriate food, but also a
consequence of other conditions, such as poor water supply and sanitation and a high prevalence of
disease
• Thus reversing the procedure is complex
• Considerable time ,a strong supportive political and policy environment remains crucial throughout
the period
• There is no “quick-fix” to this problem. Once achieved, however, the effect is likely to become
permanent, offering a substantial return on investment
82

83. References
• K Park. Park’s textbook of preventive and social medicine: Jan 2017: 24th
edition:698,699
• Alan J. Magill, Tom Solomon, David R Hill, Edward T Ryan. Hunter's Tropical
Medicine and Emerging Infectious Disease:2013: 9th Edition:989-996
• Hoffer LJ. Clinical nutrition: 1. Protein–energy malnutrition in the inpatient.
Cmaj. 2001 Nov 13;165(10):1345-9.
• Carole E Palmer. Diet and Nutrition in Oral Health: 2007: 2nd edition:98-117
• Grover Z, Ee LC. Protein energy malnutrition. Pediatric Clinics. 2009 Oct
1;56(5):1055-68.
• Adhikari M, Ramjee G, Berjak P. Aflatoxin, kwashiorkor, and morbidity. Natural
toxins. 1994 Jan;2(1):1-3.
83

84. References
• Ministry of Human Resource development, Mid day meal scheme (Accessed
on March 1st ,2019) URL at :
https://mhrd.gov.in/mid-day-meal
• Food and Agricultural Organization of United Nations , Important
programmes to combat malnutrition in India (Accessed on February
28th,2019) URL at :
http://www.fao.org/3/x0172e/x0172e08.htm
• World Health Organization , Nutrition (Accessed on March 1st , 2019) URL at :
www.who.int/topics/nutrition/en/
• World Health Organization , Malnutrition (Accessed on March 2nd , 2019 ) URL
at : www.who.int/features/qa/malnutrition/en/
84

85. 85