Role of Nutritionists inStrengthening the NutritionalScenario @ Base of Pyramid Rekha Sharma R.D. President Indian Dietetic Association, Director, Nutrition and Dietetics, Diabetes Foundation (INDIA) Former Chief Dietician, All India Institute of Medical Sciences, New Delhi.
Nutritional Challenges at BOP Increased birth rate Less of education Increased death rate - Increased IMR Less medical care Less finances Less nutritious foods Nutritional Deficiencies Infectious diseases Chronic diseases Poor maternal and child health
Nutritional challenges India faces a double burden Under nutrition and poor maternal health Increase in over weight and obesity (Under privileged migrant population from rural areas to urban slums) Nutritionists role is mandatory in both
Nutritional challenges onMigration to cities(urban slums) loss of traditional diet, Over weight and obesity Irregular ,faulty eating Coronary Heart disease High stress –work Diabetes Family deprivation Hypertension Lack of physical activity Metabolic syndrome Smoking , tobacco Stroke chewing, alcohol Hypercholesterolemia Hypertriglyceridemia
Incidence of obesity& relateddisorders – Migrant population Young Women (18 – 25 years) = 13.2% Delhi, DST Trial (2000) Urban slum ( 35 years) = 40.2% European Journal of Clinical Nutrition (2001) Urban Slum (30-60 years) = 28.2% Delhi, (2002) DST Trial Women migrant study 4,621( >35 years) overweight urban areas = 64 % rural areas = 36 % Hypertension >140/90 mm Hg = 50% Hyperlipidaemia Cholesterol > 200 mg = 25% Diabetes Blood sugar >126 mg% = 3 - 14 % DST trial (2009)
Coronary Risk Factors in Urban Underprivileged New Delhi, India 60 High W-HR 45 Hypertension High body fatPercentage 30 15 High BMI Diabetes 0 Misra et al., Eur J Clin Nutr, 2001 Misra et al., Int J Obesity, 2001 Misra et al., Diab Res Clin Pract,
Transition in Dietary Habits Carbohydrates from whole grains were being replaced by refined products Carbohydrates were also being replaced by unhealthy fats specially by SFA and TFA Fibre content of diets reduced Traditional foods replaced by modern refined foods Diet :Low in MUFA ,n3 ,fiber, high in refined Carbohydrates ,SFA,TFA ,n6
Other side :Macro and Micronutrientdeficiency Deficiency of vitamin minerals often occurs in conjunction with PEM One third of the World’s people do not fulfill their physical and intellectual potential because of unrecognized deficiencies of vitamins and minerals- Vitamin A, Iron ,Iodine, folate etc.
Malnutrition affects: • Survival • Development • Growth • Health • Productivity • Economic Growth
Most Vulnerable Groups are . . .• 0-6 year children• Pregnant Women• Lactating Mothers• Adolescent Girls• Aged
India has unacceptably high level ofmalnutrition (NFHS-III)45.9% Underweight Children (Under 3 years)22.0% Low Birth Weight Babies ( for whom birth weight reported)33.0% Women with Chronic Energy Deficiencies (30% in Men)70.0% Children (6-59 months) with anaemia55.0% , 24.0% Women and Men respectively were anaemicVitamin A deficiency & Iodine Deficiency Disorders continue to be public health problems
The picture (as per UNICEF and MI VM global progressreport)Iodine Estimated to have lowered thedeficiency Intellectual capacity by 10-15 percentage pointsIron Mental development impaired by 40-60%deficiency in6-24 m oldsVitamin A Impaired the immune system leading todeficiency an estimated one million children not reaching their 5th birthdayIodine 18 million babies being born mentallydeficiency in impairedmothers
The picture [as per UNICEF and MI VMglobal progress reportFolate Approximately 200,000 babies withdeficiency severe birth defects and 1in 10 deaths from heart disease in adultsSevere Iron Causes loss of life more than 60,000deficiency young women in pregnancy and child birth and loss of 2% GDP. This is high economic cost on virtually every developing nation---world bank
Nutritional Challenges UNICEF (2009) data shows infant mortality to be declining steadily, but is still 1726 thousand deaths for children below the age of 5 against 26787 thousand births . 40% of children below the age of 5 are under weight. Despite the countrys growing economy and an ambitious rural health initiative Over 100,000 women die from pregnancy- related causes each year – highest in the world
Nutritional Challenges While breastfeeding is nearly universal in India, less than half of children (46%) are fed only breast milk for the first 6 months, as recommended Only 23.4% of children are breastfed within one hour of birth and the prevalence is significantly lower among the non-educated mothers and in rural areas. Only 55.8% of children aged 6-9 months receive solid or semisolid food and breast milk ,making complementary feeding a high-priority to be addressed The higher the education of the mother, the better the nutrition status of themselves and their child. National Family Health Survey (NFHS-3)
Way Forward Prevention and cure for Anemia: Increasing the iron content of food through dietary intake Increasing the iron content of food through fortification Increasing iron intake through supplementation Reducing blood loss by treating for parasites Reducing blood loss from hemorrhage by improving birthing or abortion practices and post-abortion care PMs National Council on India’s Nutrition Challenges - Iron fortified Iodized Salt to be promoted to battle malnutrition for prevention and cure of Anemia One cost effective way of increasing the intake of iron, is fortification of salt with iron in addition to iodine
Nutrition Programmes Improving mothers feeding and caring behaviour with emphasis on infant and young child feeding and maternal nutrition , during pregnancy and lactation. Improving household water and sanitation. Strengthening the referral to the health system, with emphasis on prevention and control of common child diseases including acute malnutrition. Providing micronutrients. Actual implementation follow ups.
Programme recommendations: Supplementary feeding activities need to be better targeted towards those who need it most ,with clear criteria set for quality assurance and accountability. Growth-monitoring activities need to be performed with greater regularity, with an emphasis on using this process to help parents understand how to improve their childrens health and nutrition. Involving communities in the implementation and monitoring of programmes and anganwadi centers ,to improve the quality of service delivery and increase accountability in the system.
Exclusive breastfeeding preventschild malnutrition 0-6 months is critical, 6-12 is next We allow child under nutrition to set in - with poor feeding ( Breast feeding and complementary feeding) Neonatal infections, Diarrhea and pneumonia give 2/3rd mortality in 1st year According to WHO, other 2/3rd mortality is related to poor feeding practices
Way ForwardPrevention and cure for under nutrition in children There are ten proven, high-impact interventions ,that can help in bringing, child under nutrition , figures down: q Timely initiation of breastfeeding within one hour of birth. q Exclusive breastfeeding in the first six months of life q Timely introduction of complementary foods at six months q Age-appropriate foods for children six months to two years q Safe and hygienic complementary feeding practices
Way Forward 6. Full immunization and bi-annual vitamin A supplementation with deworming 7. Appropriate feeding for children during and after illness 8. Therapeutic feeding for children with severe acute malnutrition 9. Adequate nutrition and anemia control for adolescent girls 10. Adequate nutrition and anemia control for pregnant and breastfeeding mothers UNICEF
Nutrition Interventions to combat Micronutrient Malnutrtition• Fortification• Supplementation• Dietary diversification• Nutrition and health Education
DIETARY DIVERSIFICATION to combat Micronutrient Malnutrition• Horticulture interventions: Promote the Nutritious crops by providing incentive to the farmers• Nutrition and Health Education to promote healthy eating patterns – LONG TERM SUSTAINABLE intervention – BEHAVIOUR CHANGE• Promotion of correct Infant and Young child Feeding Norms• Promotion of low cost locally available nutritious food – by providing them recipes/ or demonstration of the recipes• Promotion of seasonal fruits and vegetables• Use of Hygiene and sanitary practices• Use of Safe Drinking water• Use of Mass media to promote healthy Food ,Safe , Sanitary and hygiene Practices
Fortification and supplementation Recipes suitable for infants and children Recipes which can be prepared daily specifically for the infant Adult food modified to suit children’s needs Protein-rich supplements that may be added to the family diets Ready-to-use infant weaning foods can be prepared Recipes suitable for preschool children Nutritious snacks for infants and preschool children
Nutrition Education Breast feeding practices Weaning foods at proper age Easy recipes with supplementation Cereal + Pulse mixes Use of kitchen garden fresh foods and leafy vegetables Use of millets , whole grains vs refined foods Hygiene and clean water
Conclusion Nutrition Education to mothers Breast feeding practices Weaning food practices Recipes – easy to prepare and economical Modification of family meal Supplementation of foods Migrant population - on food selection guidance –use whole grains and good quality fats.