"To eat is a necessity, but to eat intelligently is an art." - La Rochefoucauld
Nutrition can be defined as food or nourishment needed to keep an organism growing, healthy and viable. It also refers to the process of providing or receiving food or other life-supporting substances. In other words we can also say that nutrition is the process in which you consume food or nourishing liquids, digest and absorb them and use them for health and growth. Although nutrition is important not only for organisms but it is essential for plants and trees also. Nutrition is essential for
Providing energy for performing physical activities
Prevents disease and good for the heart.
Overcome illness and in recuperating.
Assists body in eliminating wastes.
History of Nutrition:
For hundreds of years the ancient Greek view was that all food contained a single essential nutrient since people were able to survive on varied diets, from coastal fish-based diets to inland meat- and grain-based diets. It wasn't until the 1700s that researchers in Europe started trying to analyze foods and realizing that a range of different foodstuffs were necessary for health. In 1753 an English researcher, James Lind, linked the disease of scurvy in sailors to a lack of fresh fruits in the diet. Once lemon juice and oranges were added to the dried meat rations, sailors were able to survive for months in relative good health. In the 1800s a soldier shot in the stomach survived the gunshot wound but was left with a gaping hole in his abdomen. William Beaumont, an American doctor, observed the inner workings of the soldier's stomach through this hole and concluded that the stomach did not grind foods mechanically but dissolved them, and foods were dissolved at different rates. Over the years these and other observations advanced the study of nutrition.
What is malnutrition?
A one year old “Jhanki” of Budhram and Santo of Bichhiya block of Mandla District is quite irritating, having cold and cough frequently and episodes of diarrhea are repeated. Budhram had very little earning from his 1.0 Acre land. They had 7 children and after Jhanki, Santo delivered a boy only 15 days ago. Jhanki is not able to even sit by herself, her ribs are easily countable. The diet of Jhanki is only dry rice which she eat around 1-2 teaspoon with water.
Jhanki is caught by malnutrition which is mainly due to poverty, ignorance and lack of nutrition. Malnutrition is a disparity between the amount of food and other nutrients that the body needs and the amount that it is receiving. This imbalance is most frequently associated with under-nutrition as well as over-nutrition but in this article we primarily focus on under-nutrition, which is the grave problem of developing India.
Under-nutrition occurs when either one or more vital nutrients are not present in the quantity that is needed for the body to develop and function normally or it may be due to insufficient intake, increased loss, increased demand, or a condition or disease that decreases the body’s ability to digest and absorb nutrients from available food.
During infancy, adolescence and pregnancy adequate nutritional support is crucial for normal growth and development.
In children two patterns of malnutrition, stunting and wasting, are recognized (Waterlow 1972; Waterlow, Buzina, & et al. 1977). Different processes produce these two patterns and they are assessed using separate anthropometric indices. Acute nutritional deficit produces wasting, characterized by a reduction in weight for height (Wt-for-Ht), or middle upper arm circumference (MUAC). Prolonged nutritional deficiency results in stunting, characterized by a reduction in height for age. Weight for age is a composite index that reflects both wasting and stunting (Gomez & et al. 1955). Wasting and stunting are associated with different functional consequences and consequently weight for height and height for age relate to different risks. Weight for height is a powerful discriminator of the risk of short-term mortality, whereas height for age relates to the risk of longer-term mortality (Bairagi 1981; Briend et al. 1989). The importance of using the correct indicator and cut-off, for the correct purpose; nutrition screening in stable situations, or screening entries into feeding centres during famine for example, is stressed in the academic literature (Bairagi et al. 1985; Chen, Chowdhury & Huffman 1980; Habicht 1980; Smedman et al. 1987) and implemented at field level (Boelaert et al. 1995; Hakewell & Moren 1991; Young 1992).
Mainly malnutrition can be divided into
Ø Under-nutrition: where either quantity of food consumption or nutrients in the food consumed are insufficient or proportion of nutrients in the food consumed are imbalanced (not as per the requirement).
Ø Over-nutrition: where quantity of food consumed and one or more nutrients are quite more than the requirement in the food consumed.
In developing countries the major problem is of under nutrition. Now a days in metros and other cities so called well to do families are facing problem of over nutrition also. But here we discuss only under nutrition which is double burden of malnutrition. This is the fact that undernutrition early in life predisposes to over nutrition and metabolic syndrome in later life (if the child survives!). This is because the body adapts to store more calories and be more economical eith food when exposed to malnutriotn in childhood - later this predisposition to store food means that they easily become obese. It is the reason that the rate of heart attack, diabetee and stroke are starting to get very high in developing countries.
Effect of malnutrition on human being
Pregnant and lactating women, adolescent and young children are most vulnerable to malnutrition. Scientific evidence has shown that beyond the age of 2-3 years, the effects of chronic malnutrition are irreversible. Child malnutrition is the biggest contributor to under-five mortality due to greater susceptibility to infections and slow recovery from illness.
Child malnutrition impacts on their educational status. The degree of cognitive impairments is directly related to the severity of stunting and Iron Deficiency Anaemia. Studies show that stunted children in the first two years of life have lower cognitive test scores, delayed enrolment, higher absenteeism and more class repetition compared with non stunted children. Vitamin A deficiency reduces immunity and increases the incidence and gravity of infectious diseases resulting in increased school absenteeism.
Child malnutrition impacts on economic productivity. The mental impairment caused by iodine deficiency is permanent and directly linked to productivity loss. The loss from stunting is calculated as 1.38% reduced productivity for every 1% decrease in height while 1% reduced productivity is estimated for every 1% drop in iron status.
Maternal malnutrition increases the risk of poor pregnancy outcomes including obstructed labour, premature or low-birth-weight babies and postpartum haemorrhage. Severe anaemia during pregnancy might result into increased mortality risk during and after delivery.
Low-birth-weight of a baby is a significant contributor to infant mortality. Moreover, low birth-weight babies who survive are likely to suffer growth retardation and illness throughout their childhood, adolescence and adulthood also. Growth-retarded adult women are likely to carry on the vicious cycle of malnutrition by giving birth to low birth-weight babies.
Malnutrition and infection operate in a vicious mutual synergism. Malnutrition predisposes to infection and increases the severity and mortality of infections. Infection reduces nutrient intake, interferes with substrate utilization and promotes tissue breakdown. Malnutrition and infection tend to occur in the same populations: resource-poor settings, poverty, and extremes of age are major risk factors; hospitalized patients are also at significant risk. A history of weight loss is an important indicator of macronutrient deficiency.
“Primary” and “Secondary” malnutrition
The term malnutrition is being used to denote a clinical condition comprising several overlapping syndromes. In adults, wasting, a decrease in body mass, is common among all these syndromes, whereas in children, a failure of growth is the unifying feature. In any individual, the most important cause is an inadequate supply of energy or other nutrients, in respect to metabolic demands. The reasons for this inadequate supply against demand can be classified as either primary or secondary. Primary malnutrition develops when nutrient intake is insufficient to cater for normal physiological needs. In children this might be due to either, absence of sufficient food, or to the inappropriate composition of food, for example a diet with an insufficient nutrient density. In adults, primary malnutrition is invariably due to an absence of sufficient food.
Secondary malnutrition occurs when an underlying disease process increases metabolic demands or decreases food intake or both. Wide ranging metabolic, hormonal and cytokine-related abnormalities are involved. These are different to that seen in primary malnutrition.
Severe acute malnutrition
There are several important points that characterise severe acute malnutrition (SAM):
· Severe acute malnutrition is defined by a very low weight for height (below -3z scores of the median WHO growth standards), by visible severe wasting, or by the presence of nutritional oedema. Decreasing child mortality and improving maternal health depend heavily on reducing malnutrition, which is responsible, directly or indirectly, for 35% of deaths among children under five.
· It is an “acute” condition where dietary intake is insufficient for metabolic demands, resulting in a continuing loss of body tissue.
· It is “severe” in that if untreated it leads quickly to death.
In Madhya Pradesh a number of malnutrition deaths were occurred in Jhabua, Khandawa, Satna and Shivpuri districts. Although government is denying the fact that deaths are not due to malnutrition they had diarrhea or fever or some other disease. But the fact is that the child having malnutrition is susceptible to infections and due to malnutrition he/she was infected and died
Status of malnutrition:
Malnutrition is a major public health problem throughout the developing world and is underlying factor in over 50% of the 10-11 million children under 5 years of age who die each year of preventable causes. Worldwide there are about 60 million children with moderate acute and 13 million with severe acute malnutrition. About 9% of Sub Saharan Africa and 15% of South Asian children have moderate acute malnutrition and about 2% of children in developing countries have SAM. In India
The World Bank estimates that India is on 2nd rank in the world of the number of children suffering from malnutrition, where 47% of the children exhibit a degree of malnutrition. The number of underweight children in India is among the highest in the world, and is nearly double that of Sub-Saharan Africa with dire consequences for mobility, mortality, productivity and economic growth. The UN estimates that 2.1 million Indian children die before reaching the age of 5 every year – four every minute - mostly from preventable illnesses such as diarrhea, typhoid, malaria, measles and pneumonia. In India, every day about 1,000 children die due to diarrhea related causes.
If data provided by the Government of Madhya Pradesh are being analysed, about 57 lakhs of children in Madhya Pradesh are malnourished. Also the National Family Health Survey-III (NFHS) has also brought out the grim public health situation in the state. According to the NFHS-III, 60 per cent of the children in the 0-3 years category in Madhya Pradesh are malnourished, with 82.6 per cent children in the same age group being anaemic.
The Infant Mortality Rate (IMR) in the State stands at 70/1,000, while IMR for tribal areas is 95.6/1,000.
Lack of food or nutrients does not show symptoms of malnutrition within a day or a week. Only water soluble Vitamins (i.e., B and C) might show early symptoms of their deficiencies. Some times body adjust itself as per the diet consumed and many times if the body stores have enough quantity of nutrient in the store might be used for body requirements but after some period if the deficiency could not be surmounted then the symptoms of deficiency of that nutrient can be observed. Symptom of deficiency of one or more nutrient might also be observed at the same time.
Food quantity and quality:
If the food consumed is appropriate in terms of quantity and have sufficient quantity of nutrient in appropriate proportion the food is called balanced food. Food quantity and quality depends on several other factors also:
² Poverty affects buying capacity of families thus resulted into less quantity as well as frequency of food consumed
² Illiteracy and unawareness regarding nutrients resulted into inappropriate quality of food and proportion of nutrients are also improper. Thus although the family has sufficient quantity of food to consume and also even in well to do families also they are spending money in buying products which are less nutritive and resulted into under-nutrition or over-nutrition
² Natural Calamities like earthquake, flood, drought, etc. directly affect availability of food grains and other items although some times people have money but sufficient food is unavailable.
² Cultural values and customs also make community vulnerable like a lactating mother could not be consume fruits and salads, even in some communities she did not provided any food for 2-3 days. In many communities pregnant woman used to consume less amount of food resulted in malnutrition of woman as well as fetus.
Health, Sanitation and Environment:
Inadequate sanitation and hygiene is a major contributing factor for anaemia due to intestinal worm infection. Health and nutrition are closely linked in a “malnutrition-infection cycle” in which diseases contribute to malnutrition, and malnutrition makes an individual more susceptible to disease.
Acute conditions such as surgery, severe burns, infections, and trauma can drastically increase short-term nutritional requirements. Those patients who have been malnourished for some time may have compromised immune systems and a poorer prognosis.
Chronic diseases may be associated with nutrient loss, increased nutrient demand, and/or mal-absorption. Mal-absorption may occur with chronic diseases such as celiac disease, cystic fibrosis, pancreatic insufficiency, and pernicious anemia. An increased loss of nutrients may be seen with chronic kidney disease, diarrhea, and hemorrhaging. Decreased appetite, difficulty swallowing, and nausea associated both with cancer (and chemotherapy) and with HIV/AIDS (and its drug therapies), increased loss, mal-absorption, and decreased intake may also cause malnutrition.
Nutritional trends of various demographic groups:
Many other factors, i.e, region, religion, caste, gender, etc. also affect the nutritional status.
o Gender may also leads to malnutrition as in Indian culture women tend to eat in the last. At that time she may not to take all the variety which is cooked and eaten by other members (children, and male members) of the family or she wants to finish remaining items (they might be more quantity of even one or two items. At present a fashion of “zero-figure” is prevalent among adolescent girls so they are practicing dieting which also leads them to the problem of under-nutrition. Thus these females has higher risk of both under and over-nutrition than men. Nearly 50% of females aged 15–19 face under-nutrition, with a very low percentage of over-nutrition.
o Socio-economic status of those who are poor are at risk for under-nutrition, while those who have high socio-economic status are relatively more likely to be over-nourished.
o Region of residence like rural area also contribute to nutritional status. In tribal areas of Madhya Pradesh people are quite away from vegetables, fruits and pulses. Cereals are also not available in sufficient quantity. These tribal only rely on rice (as Pege) and some dried leafy vegetables like, chakora, etc. Only for a very few days in a year they are able to consume maize and maize again contributes in occurrence of pellagra (deficiency of Vitamin Niacin B3. Anaemia among both men and women is only slightly higher in rural areas than in urban areas. In urban areas, overweight status and obesity are over three times as high as rural areas. In terms of geographical regions, Madhya Pradesh, Jharkhand, and Bihar have very high rates of under-nutrition. States with lowest percentage of under-nutrition include Mizoram, Sikkim, Manipur, Kerala, Punjab, and Goa, although the rate is still considerably higher than that of developed nations. Further, anaemia is found in over 70% of individuals in the states of Bihar, Chhattisgarh, Madhya Pradesh, Andhra Pradesh, Uttar Pradesh, Karnataka, Haryana, and Jharkhand. Less than 50% of individuals in Goa, Manipur, Mizoram, and Kerala have anemia. Punjab, Kerala, and Delhi also face the highest rate of overweight and obese individuals.
o Religion of human is also have effect on their nutritional status as studies show that individuals belonging to Hindu or Muslim backgrounds in India tend to be more malnourished than those from Sikh, Christian, or Jain backgrounds.
o Caste i.e., belonging to scheduled castes, schedules tribes, or other backwards castes also has increased risk of malnutrition. In particular, children of scheduled tribes have the poorest nutritional status and the highest wasting.
o Elderly patients require fewer calories but continue to require adequate nutritional support. They are often less able to absorb nutrients due to decreased stomach acid production and are more likely to have one or more chronic ailments that may affect their nutritional status. At the same time, they may have more difficulty preparing meals and may have less access to a variety of nutritious foods. As today many children settled away from their parents and nuclear families are in prevalence thus elderly persons are living alone. Older patients also frequently eat less amount of food due to a decreased appetite, decreased sense of smell, and/or mechanical difficulties with chewing or swallowing.
Nutrients deficiency:
As per the deficiency of nutrients broadly following types of malnutrition may be observed:
o Protein deficiency,
o Vitamin A deficiency
o Vitamin B complex deficiency
o Vitamin C deficiency
o Vitamin D deficiency
o Iron deficiency
o Iodine deficiency
o Protein deficiency
Protein deficiency leads to malnutrition. Malnutrition due to lack of protein is observed at the age of weaning i.e., after 6 months or if they could not provided breastfeeding. When the children do not get enough protein giving foods, their bodies become thin and they feel weak. Major causes of this type of malnutrition are “poverty” and “lack of knowledge” where parents are unable to provide enough quantity of food to fulfill child’s need. Malnourished children look old and wrinkled. Their skin is dry and their faces are thin, with sunken cheeks and large eyes. Their abdomen looks swollen. They present sagging skin on legs and buttocks.
Children cry a lot, very irritable and have increased greedy appetite. They are liable to all kind of disease.
Other signs of protein malnutrition are:
· Dizziness
· Chronic fatigue or lack of energy.
· Dry, scaly or flaking skin.
· A low immune system which cannot fight off infections and illness.
· Loss of weight or being underweight.
· Slowed reflexes.
· Inattentiveness or trouble remembering.
· Stinted growth.
· Bloated stomach if malnutrition is severe.
· Muscle weakness and trembling.
· Hair thin, rare and dull
· Skin Wrinkles
· Apparent rib, etc.
For measuring malnutrition among children it is essential to follow weight for age matrix. Now a days WHO recommended new type of growth chart which has only three grades i.e., normal, low weight and very low weight. In other words they are called Normal, Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM). These grades are considering boys and girls differently, while before this the growth charts considered them same. Following are the newly adopted growth charts separately for boys and girls. In these charts birth month and the year has to be written in very first column of X-axis and gradually one-by-one month has to be written. On Y-axis weights of that particular month is to be plotted. Weight of the child in the concurrent month is to be taken and plotted on the chart in the same column on the row displaying weight. According to this point status of the child’s growth is being considered.
Growth charts can only reflect protein and protein-energy malnutrition. For detecting other types of malnutrition we have to observe other clinical symptoms as well as pathological diagnosis can be performed accordingly.
Micronutrient malnutrition:
Micro nutrients are the nutrients required by the body in small quantity although they will not provide energy to the person but they are essential for vital activities performed by the body. Under this section only major micronutrients i.e., Vitamin A, Vitamin B complex, Vitamin C, Vitamin D and minerals like iron deficiency and iodine deficiency will be covered.
o Vitamin A Deficiency (VAD)
As Vitamin A is fat soluble deficiency of Vitamin A can occur when people take diet which has insufficient quantity of vitamin A or fat. Vitamin A deficiency can cause night blindness and permanent damage to the eyes, blindness and even death. People at risk from vitamin A deficiency are mostly pregnant and breastfeeding mothers and children. Vitamin A is fat soluble vitamin thus shows disorder due to high intake also. it is necessary take it in balance quantity. Those who lack Vitamin A can lose much or all of their vision. Vitamin A deficiency is the leading cause of blindness in children that live in Third World countries. These children have a high risk of illness and can easily die from childhood diseases such as measles, mumps and chickenpox. Diarrhea can also be fatal.
Prevention of Vitamin A Deficiency (VAD):
² Increase Vitamin A intake through consumption of yellow/orange fruits and vegetables and fortified foods available in the market.
² Because Vitamin A is fat-soluble you should ensure you get an adequate source of fat and oil. Good sources of these that can be grown at home include sunflower oil, nuts and seeds (ground-nuts, sesame seeds, round-nuts, sunflower seeds, pumpkin seeds), peanut butter and avocado.
² Infants should be exclusively breastfed for the first six months and continue to be breastfed up to twenty-four months.
² Mothers should take Vitamin A within 8 weeks after giving birth (200,000 IU).
² Children from 6 to 59 months should get Vitamin A supplementation orally every 6 months (6 months - 1 year: 100,000 IU; >1 year: 200,000 IU). But according to Prof. Umesh Kapil supplementary dose of Vitamin A is toxic. The mega-dose of vitamin A (200 000 IU) given to children is 500 times higher than the daily recommended dose (400 IU).
Adults with impaired immune systems and children suffering from measles, persistent diarrhoea, acute respiratory infection, chickenpox, severe malnutrition and xerophtalmia should receive treatment dose of Vitamin A.
o Vitamin B Complex deficiency
Vitamin B is a complex of 12 essential vitamins. Some of these members are Thiamine (Vitamin B1), Riboflavin (Vitamin B2), Niacin (Vitamin B3), Pantothenic Acid (Vitamin B5), Pyridoxine (Vitamin B6), Biotin, Folic Acid and the Cobalamins (Vitamin B12). None of the food source has all the members of this complex it is important to take mix food diet to fulfill its requirement. They cannot be stored in bodies, so we depend entirely on our daily diet to supply them. Vitamin B complex is destroyed by alcohol, refined sugars, nicotine, and caffeine. Vitamin B complex is a water soluble vitamin and thus its extra quantity in daily diet will exit from the body through urine, sweat, etc. Vitamin B complex is essential for health of skin, digestion of food, blood synthesis, and various other voluntary activities which could be controlled by human. Because of its water solubility it even evaporates during cooking if cooked uncovered and cooked in plenty of water and the water used in cooking is disposed off. Even if food stuff is washed many times or through mashing with hands all the vitamin B complex will thrown away.
o Vitamin C deficiency
Vitamin C is also a water soluble Vitamin thus the same conditions will be observed as in Vitamin B complex. In addition to this vitamin C is very sensitive towards temperature and by heating and cooking it destroys. Even exposure to sun light and air will help destroying vitamin C. Only Amla has unique characteristic to prevent destroying some quantity of Vitamin C even after sun drying. Vitamin C is essential for preventing infection and for early healing of wounds. Stress, pregnancy, and lactation increase the body's need for vitamin C, while aspirin, tetracycline, and birth control pills can deplete the body's supply. Main symptoms of Vitamin C deficiencies are badly decayed teeth, swollen and/or bleeding gums, repeated infection of cough and cold, late healing of wounds, unhealthy skin and hairs, aneamia, etc.
o Vitamin D deficiency:
Vitamin D is fat soluble vitamin and it can be synthesized by the body with sunlight. In the absence of Vitamin D, calcification of bones is not being done properly. Thus it is essential for the health of bones. Deficiency of Vitamin D is being observed in the form of Rickets.
If a person is exposed to sunlight for sufficient period or consuming animal products even like milk of an animal which has sufficient exposure to sunlight his/her body itself synthesize Vitamin D.
Minerals
Minerals are required in less quantity. They are available in vegetables and fruits and as common salt. Long term deficiencies in the diet of a person leads to there deficiency.
Magnesium: Deficiency might result into depressive symptoms, along with confusion, agitation, anxiety, and hallucinations, as well as a variety of physical problems. Most diets do not include enough magnesium, and stress also contributes to magnesium depletion
Calcium: Deficiency affects central nervous system of a person. Low levels of calcium cause nervousness, apprehension, irritability, and numbness. Osteoporosis is also observed during lack of calcium, which causes bones to break easily. During pregnancy requirement of calcium increases as the fetous require calcium for formation and growth of his bone, teeth, etc. Lack of calcium in pregnant women diet resulted into osteoporosis as fetous take calcium for his requirement from the bones of mother and due to osteoporosis mothers bones become weak and might get fractured even on slight jerk.
Zinc: Inadequacies result in apathy, lack of appetite, and lethargy. When zinc is low, copper in the body can increase to toxic levels, resulting in paranoia and fearfulness.
Manganese: This metal is needed for proper use of the B-complex vitamins and vitamin C. Since it also plays a role in amino-acid formation, a deficiency may contribute to depression. Manganese also helps stabilize blood sugar and prevent hypoglycemic mood swings.
Potassium: Depletion is frequently associated with depression, tearfulness, weakness, and fatigue.
Sodium: Deficiency as well as hyper availability adversely affects maintenance of blood pressure and functioning of kidney.
Iron and Iodine play vital role thus discussed in details.
Iron Deficiency Anaemia (IDA)
Iron is essential for synthesis of blood. Hemoglobin is the main constituent of blood which is complex of heme and globin. Heme is synthesized by iron while globin is made of protein. This hemoglobin is essential for circulation of oxygen from Lungs to heart and from heart to farthest part of body. Thus lack of iron resulted into lack of or diluted hemoglobin resulted into shortage of oxygen supply to body parts for there uninterrupted work. During pregnancy fetous is also depending for nutrition and oxygen supply for his growth on hemoglobin of mother. Thus lack of iron which causes anaemia resulted into many disorders related to pregnancy. It may result into maternal mortality due to hemorrhage. Lack of iron causes children to be lethargic and inattentive. Children and teens who suffer from malnutrition will experience decreasing academic grades. Thus Iron Deficiency Anaemia affects women and children in particular, as well as adolescents and the elderly. It makes people feel exhausted and slows down learning in children. Anaemia increases the risk of problems for mother and baby during and after delivery.
Signs of anaemia include a pale tongue and inside of the lips, tiredness and breathlessness. Shape of nails can also shows its deficiency. In severe deficiency spoon shaped nails are observed.
For prevention of anaemia one should:
² Increase Iron intake by taking green leafy vegetables.
² Rice flakes, watermelon, jaggary, are also good sources of iron.
² Eat "Iron Helpers" such as guava, oranges, lemon or other Vitamin-C sources
² Avoid 'Iron Blockers' like tea, coffee and milk for one hour before and one hour after eating an iron-rich meal.
² Prevention of Malaria is also useful in prevention of anaemia
² Prevention of hookworm also increases hemoglobin level of individual. Thus to prevent worm infestation take de-worming tablets twice a year. For reduction of possibilities of worm infestation it is essential to wear shoes, proper disposal of faeces, and washing hands and nails thoroughly before preparing food and eating.
² Taking iron tablets as directed by a health worker:
Iodine is available in the soil or rocks and thus available in the crops produced here and the water flowing on these rocks. Thus deficiency of iodine was observed at the places where iodine is not available in soil or on rocks. Iodine deficiency can cause delayed development, autism and mental retardation.
Iodine Deficiency can lead to different grades of goitre and cretinism. Goitre is characterized by a palpable and visibly enlarged thyroid with neck in normal position. Iodine deficiency may lead to over activity (hyper) of thyroid gland.
Prevention of Iodine Deficiency Disorders (IDD):
· Purchase packaged iodized salt.
Vulnerable groups for malnutrition:
For malnutrition of any type some population groups of vulnerable or they might caught by nutrient deficiency earlier then others. These groups are:
² Low birth weight babies
² Children under 5 years
² Adolescent boys and girls
² Pregnant women
² Lactating mothers
² Women of reproductive age i.e., 15-45 years
² Elderly persons
² Disable persons
² Persons suffering from chronic disorders
² Persons recently gone under surgery
² Poor and marginalized population
Prevention of malnutrition:
For prevention of malnutrition it is necessary to take balanced diet in sufficient quantity. Some other factors those might contribute in prevention of malnutrition are:
o High protein diet is essential for all the above mentioned vulnerable groups. For high protein diet one should add pulses, peas, groundnuts, soyabeans, milk and milk products like paneer in his daily diet. Soyabean is a richest source of protein and might be used as flour supplement Protein from animal sources like, eggs, fish, meat and other flesh foods are better in comparison with vegetable sources as they have all essential amino acids.
o Frequent nutritious diet may help during the state of lack of appetite and weak digestive system. Frequent nutritious diet meant by low quantity of food having quality of nutrients may be consumed in less intervals.
o Low cost nutritious recipes are useful in preventing malnutrition due to poverty. Poverty also resist person to buy variety of food thus it is necessary to use locally available food stuffs for preparing low cost recipes.
o Mixed diet is essential for making diet balanced. None of the food stuff have balance amount of all essential nutrient. Thus to take balanced diet it is essential to mix two or more type of food groups like, cereals-pulses, pulses-vegetables, cereals-pulses-vegetables, etc. In Indian culture majority people are using many mix diets like khichadi (prepared by dal and rice), if some vegetable like spinach, potato, tomato, peas etc. are added to it its nutritious value will increased.
o Iodized salt when used will help in prevention of iodine deficiency.
o Use of iron rich sources help in prevention of anaemia.
o Sources for Vitamin A if taken is sufficient quantity will prevent deficiency of Vitamin A but due to its fat solubility its hyper consumption also shows symptoms like vomiting, and even death may be occurred due to it.
Government schemes to prevent all types of malnutrition
The Government of India has launched several programs to converge the growing rate of under-nutrition among children. These schemes include supplementary nutrition in ICDS, Mid day meal in school education, Nutrition Rehabilitation Centres under National Health Mission, Vitamin A supplementation through Micro Nutrient Initiative, IFA Supplementation through Public Health and Family Welfare Ministry, Iodized salt promotion, etc.
Supplementary Nutrition Program under ICDS
The Government of India has started a program called Integrated Child Development Services (ICDS) in the year 1975. It is a unique program of the World. Objective behind this program is to fulfill daily nutritional requirement of the beneficiary which could not be completed at home. ICDS is providing supplementary nutrition to children of 6 months to 6 years, pregnant women, lactating mothers and adolescent girls those are vulnerable towards malnutrition. Supplementary nutrition is providing 1/3 requirement of protein and calories. This is not a full meal but it is supplementary because what a person has eating at home should not be replaced with this food.
Mid Day Meal Program under School Education
Government has started Mid day meal program under school education for the students of Primary Schools but later on it is extended upto Middle Schools. Objective of this program is to provide food to students so that they will come to school for its attraction and child labour and school drop out should be prohibited. In Mid day meal program a child has provided cooked food of minimum 450 calories and 12 grams of protein.
Nutritional Rehabilitation Centres (NRCs) under NRHM
This mission was created for the years 2005-2012, and its goal is to "improve the availability and access to quality health care by people, especially for those residing in rural areas, the poor, women, and children". The mission has established Nutrition Rehabilitation Centres for providing therapeutic treatment to Severely Malnurioushed Children (SAM). In MP at present there are 209 NRCs are functional while it is proposed to have 1 functional NRC in each of the 313 blocks by 2010-11. In these NRCs children are kept in friendly atmosphere and their parents accompany them. After getting discharge from the NRC, ICDS as well as health functionaries and ASHAs are making follow up visits.
Vitamin A supplementation through Micronutrient Initiative (MI):
Children of 9 months to 5 years are provided Vitamin A supplementation at the interval of 6 months. Children below one years are providing 1,00,000 IU (International Units) of Vitamin A while children more than one year of age are getting 2,00,000 IU Vitamin A once in six months. Precaution is being taken that the dose should not be repeated within six months as it develops symptoms of hyper vitaminosis A.
IFA supplementation in schools, Anganwadi Centres and health centres:
Children below 6 years, pregnant women, adolescent girls and school going children are being provided Iron and Folic Acid Supplementation (IFA). Women in the age group of 15-45 years having symptoms of anaemia are also getting IFA under the programme. During pregnancy if a pregnant women is consuming dose of 100 tablets of IFA. She might not face problem of hemorrhage during delivery. If a pregnant women is still anaemic after consumption of 100 IFA tablet dose of IFA can be repeated under Doctors consultation. In Primary and Middle Schools all the children getting Mid day meal are provided 1 small tablet of IFA per day. Adolescent girls and children at Anganwadi Centres are also getting IFA. There are two types of IFA tablets are supplied under Government Scheme Big Tablet for women and adolescent girls and small tablets for children. Big IFA tablet have 20 mg iron and 500 µg folic acid while small tablet have 10 mg iron and 100 µg folic acid.
Management of all types of malnutrition
o Community based management of malnutrition
The community based management of severely acute malnourished children does not having other symptoms might be treated in the community. Focus of the program will be on following principals:
1. Maximum access and coverage
2. Timeliness (early detection of SAM)
3. Continued care and unhindered access to prevent any relapse.
The community based therapeutic care provides effective care to the majority of acutely malnourished children. As outpatients, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. Children with severe acute malnutrition without medical complications are treated as an outpatient therapeutic program with ready to use therapeutic food and medication.
Under this program the quality of engagement with target communities is a vital determinant of the success of a community based program. For community based program community should be effective, sensitization of the community aims to raise awareness of the program, promote understanding of its methods and lay foundation for ownership in the future.
Thus, although it is a serious problem and many efforts are being taken place for its reduction and prevention but know seriously Government is making efforts either as NRC or as Community based therapeutic treatment of malnourished children. Let us hope that we will able to reduce malnutrition not from the state but also from the country.
o Nutrition Rehabilitation Centre (NRC)
Nutrition Rehabilitation Centre is the place where severely malnourished (SAM) children having need of getting treatment under technical supervision. These centres are children friendly and they got all the medicines and diet from the centre free of cost. These children could not be treated within community thus needs hospitalization. A recent analysis of the NRCs shows that 65% children got cured at NRCs, 5% were medical transfers, 21% were defaulters, while 9% were non-responders and there were 1% deaths.
In nutrition rehabilitation centre all patients:
² Admitted patients should be registered and all information recorded in the Multichart including the target weight for discharge (WHO/NCHS table).
² Admitted patients should be provided with a systematic medical examination and given routine medicine
² Children in Phase 1 should be together in a separate room and not mixed with other patients because of their special diet requirements. Use identification bracelets if there is no separate room or space.
² It is important to provide mother/care givers with all necessary equipment at admission: blanket, mug, plate, etc.
² F75 is the starter formula to use during initial management. Severely malnourished children cannot tolerate usual amounts of protein and sodium at this stage, or high amounts of fat. They may die if given too much protein or sodium. They also need glucose, so they must be given a diet that is low in protein and sodium and high in carbohydrate. F-75 is specially made to meet the child's needs without overwhelming the body's systems in the initial stage of treatment. Use of F-75 prevents deaths.
² Children in Phase 1 need to receive daily surveillance:
o Weight is measured, entered and plotted on the Multichart.
o The degree of oedema (0 to +++) is assessed and noted in the Multichart.
o Body temperature is measured twice a day and noted in the Multichart.
o Standard clinical signs (stool, vomiting, dehydration, cough, respiration and liver size) are assessed and noted in the Multichart.
o Breastfeeding children should always get the breast milk before the diet and on demand.
² Supervision of feeding: Sharing of the mother's meal with the child can be very dangerous for the malnourished child. Peer supervision among mothers should be encouraged to promote appropriate feeding practices. The meals for mothers should never be taken beside the patient because it is almost impossible to stop a child demanding some of the mother's meal. If the mother's meal has added salt or condiment it can be sufficient to provoke heart failure in the malnourished child.
² Feeding technique: The child should be on the mother's lap against her chest, with one arm behind her back. The child should never be force fed. Naso-gastric tube (NGT) feeding is used when a patient is not able to take sufficient diet by mouth (that is defined as an intake of less than 75% of the prescribed diet). Other reasons for using NGT include: 1) Pneumonia with a rapid respiration rate; 2) Cleft palate or other physical deformity; 3) Painful lesions of the mouth and 4) Disturbances of consciousness. The use of NGT should not normally exceed three days and should only be used in Phase 1.
² Treatment of medical complications for severely malnourished children should follow standard WHO protocols for the seven steps of initial phase care taking into account national policy.
² Careful diagnosis of dehydration (history and clinical signs) need to be done before using a rehydration solution like Resomal and should be accompanied by hourly monitoring.
² The routine use of IV fluids is discouraged and should only be used to resuscitate severely acutely malnourished children from shock.
[2] Addressing India
[3] State Level Consultation on Community –Based Management of Severely Acute Malnourished Children in MP. Department of Women and Child Development GoMP. Bhopal. P. 3
[4] State Level Consultation on Community –Based Management of Severely Acute Malnourished Children in MP. Department of Women and Child Development GoMP. Bhopal. P. 3
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