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DEPARTMENT OF PUBLIC
NUTRITIONAL PROBLEMS IN PUBLIC
Submitted by Guided by
Mayank Chhangani Dr. Gaurav Chhabra
Final Year Dr. Daman Gupta
Dr. Nikku Nebwani
There are many
which affect vast
segments of our
population. The major
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
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.
• 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:
a) Inadequate intake of food both in quality and quantity
b) 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
• Malnutrition is self perpetuating.
• A child’s nutritional status depends upon his or her past
nutritional history as shown in the figure:
The principle features of Kwashiorkor
and Marasmus are:
Classification of Protein Energy Malnutrition
1. 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.
• disadvantages of Gomez’ Classification are
a) cut off point of 90% of reference is high, thus some normal children may
be classified as 1st degree malnourished.
b) 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
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
• Waterlow’s classification defines two groups for PEM
a) malnutrition with retarded growth, in which a drop in the height/age
ratio points to a chronic condition-shortness, or stunting:
b) 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:
a) children with insufficient but well proportioned growth, and
b) those with a normal weight, but who are wasted
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
a) Health Promotion
1. Measures directed to pregnant and lactating women.
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. Nutrition education- promotion of correct feeding practices.
5. Home economics.
6. Measures to improve family diet.
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.
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 programs for early rehydration of children with diarrhea.
5. Development of supplementary feeding programs during epidemics.
6. Deworming of heavily infested children.
1. Nutritional rehabilitation services.
2. Hospital treatment.
3. Follow-up care.
• 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
• It is often associated with Protein Energy Malnutrition.
• Victims belong to the “Poorest Families”.
• Risk factors include
2. Faulty feeding practices and
3. 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.
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.
a) 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
b) 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.
c) Long Term Action:
These are measures aimed at “Reduction or elimination of factors
contributing to ocular disease. All these are components of Primary
• 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
• 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
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
• The most frequent cause of Nutritional Anemia is Iron deficiency
• Major nutrition problem.
• Many have iron deficiency without
• Highest among women and young
children (about 60-70%)
• Foliate deficiency anemia affects 25-
50% of pregnant women
• Highest prevalence in developing
• Found in women of child bearing
age, young children and during
pregnancy and lactation
• In developing countries, affects
about 2/3rd 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
• Detrimental effects of anemia can be seen in three important areas
• 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.
• Due to parasitic e.g. malaria, intestinal parasites
• Iron deficiency may impair cellular responses and immune functions and increase
susceptibility to infection
III. 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
• This has great significance in the economy of the country
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.
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
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
• Goitre Control
There are four essential components of National Goitre Control
Programme. These are Iodized Salt, Monitoring and
Surveillance, Manpower Training and Mass
1. Iodized Salt
• Most widely used Prophylactic Public Health Measure against endemic goitre
• Level of iodization is fixed under the Prevention of Food Adulteration (PFA)
• 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
2. 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
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 contorl including legal
enforcement and public education.
4. 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
6. 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
1. 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
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
Mottling is best seen on maxillary incisors
It is almost confined to permanent and develops only during the period of
2. 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
3. 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
1. 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
2. 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
3. Other measures
Fluoride supplements should not be prescribed for children who drink fluoridated
Use of fluoride toothpaste in areas of endemic fluorosis is not recommended for
children up to 6 years of age