NUTRITION RELATED HEALTH PROBLES (MICRO).pptx

N u t r i t i o n r e l a t e d
h e a l t h p r o b l e m s
RELATED TO MICRONUTRIENTS

Introduction
Nutrition may be defined as the science of
food and its relationship to health
• Macronutrients : proteins, fats & carbohydrates
• Micronutrients : vitamins & minerals, required in
small amounts which may vary from a fraction of a
milligram to several grams
Nutrition related health problems 2

Hidden hunger:
(micronutrient deficiency)
a form of undernutrition that occurs when intake or
absorption of vitamins and minerals is too low to
sustain good health and development in children
and normal physical and mental function in adults

Overview
Common nutrition related health disorders,
related to micronutrients:
• Iron
• Iodine
• Zinc
• Vitamin A

IRON
Function Sources
• Binding oxygen to blood
cells
• Oxygen transport
• Cell respiration
• Formation of hemoglobin
• Haem iron:
animal sources
• Non-haem iron:
vegetable origin
5
• Adult human body contains 3-4 g iron
• 60-70% in blood as circulating iron, rest 1-1.5 g as storage iron
• 1 gram hemoglobin contains about 3.34 mg iron
Nutrition related health problems

Absorption Losses
• Duodenum and upper small
intestine
• Inhibitors: e.g., phosphates
• Promoters e.g., ascorbic
acid-rich foods
• Absorbed iron stored in
liver, spleen, bone marrow
and kidney
• Liberated iron from broken-
down RBCs reutilized in
formation of new red cells
• Total adult daily iron loss:
about 1 mg
• Menstruating women: about
12.5 mg per 28 days cycle
• Major routes of iron loss
Hemorrhage
Basal losses
• IUDs increase monthly blood
loss by 35-146%
• Hormonal contraceptives
decrease menstrual blood
loss by about 50%
6

IRON DEFICIENCY
Three stages
First stage
decreased storage of iron
without any other detectable
abnormalities
Intermediate stage
“latent iron deficiency”
Iron stores exhausted, but
anemia has not occurred
percentage saturation of
transferrin falls to less than 15
per cent
most widely prevalent stage in
India
Third stage
overt iron deficiency
decrease in the concentration
of circulating hemoglobin
The end result of iron deficiency is nutritional,
a syndrome caused by malnutrition in its widest sense

Diagnosis of anemia
Category
g/dl
(venous blood)
MCHC
(per cent)
Adult males 13 34
Adult females, non-pregnant 12 34
Adult females, pregnant 11 34
Children, 6m-6y 11 34
Children, 6-14y 12 34
WHO: “Anaemia or deficiency should be considered to exist” when
hemoglobin is below the following levels:

Evaluation of iron status
Hemoglobin concentration Serum iron concentration
• Values below normal
(previous table) indicate
anaemia
• Values <0.50 mg/L
indicate probable iron
deficiency
9
Serum ferritin
Serum transferrin
saturation
• Values <10 mcg/L indicate
absence of stored iron
• Should be above 16%
• Normal value is 30%

IRON REQUIREMENTS
Category RDA (mg) Category RDA (mg)
Men 19 Children 7-9y 15
Women 29 Boys 10-12y 16
Pregnant women 27 Girls 10-12y 28
Lactating mother 23 Boys 13-15y 22
Infant 6-12m 3 Girls 13-15y 30
Children 1-3y 8 Boys 16-18y 26
Children 4-6y 11 Girls16-18y 32
• Due to recycling of iron, only small amount of iron is needed by the body
• Iron requirements are greater during pregnancy, childhood & adolescence
• The recommended dietary intakes of iron are

NUTRITIONALANAEMIA
GLOBAL
WHO estimates that 42%
of children less than 5
years of age and 40% of
pregnant women
worldwide are anaemic
INDIA (NFHS-5)
67% children age 6-
59 months have
anaemia
57% women have
anaemia
52% pregnant
women have
anaemia
MANIPUR (NFHS-5)
42.8% children age 6-59
months have anaemia
29.4% women have
anaemia
“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”

Detrimental effects
• increased maternal & fetal morbidity & mortality
• abortions, premature births, postpartum
haemorrhage, low birth weight
Pregnancy
• can be caused or aggravated by parasitic diseases
• impaired cellular responses and immune functions
and increase susceptibility to infection
Infection
• causes impairment of maximal work capacity
• more severe the anaemia, the greater the reduction in
work performance, and thereby productivity
Work
capacity

INTERVENTIONS
13
Prophylactic Iron Folic Acid
supplementation
Deworming
Intensified year-round BCC
Campaign
Testing of anemia using digital
methods and point of care
treatment
Mandatory provision of Iron
Folic Acid fortified foods in
public health programmes
Addressing non-nutritional
causes of anemia

14
6-59 months
• Biweekly
• 1ml IFA syrup
• 20mg iron,
100μg Folic
acid
5-9 years
• Weekly
• 1 IFA tablet
• 45mg iron +
400μg FA
• Pink colour
10-19 years
• Weekly
• 1 IFA tablet
• 60mg iron +
500μg FA
• Blue colour
20-49 years
women
• Non-pregnant,
non lactating:
weekly
• Pregnant,
lactating (0-
6m child):
daily
• 60mg iron +
500μg FA
• Red colour
Prophylactic Iron Folic Acid supplementation

15
Deworming
Children & adolescents
• National Deworming Day (NDD), Biannually (10 Feb & 10 Aug)
• Mass deworming, 1-19 years old
Newly wed/married women 20-24 years
• Non-pregnant, non-lactating women
• Biannually (during NDD)
Pregnant women
• Under RCH, via ANC clinics, VHND, PMSMA
• During 2nd trimester

16
Intensified year-round BCC Campaign
Compliance to Iron Folic Acid supplements and
deworming
Appropriate Infant and Young Child Feeding
Increase intake of nutrient-rich foods and food
fortification
Promoting practice of delayed cord clamping followed
by early initiation of breastfeeding

17
Testing and treatment of anaemia
Target group A: 6-59 months
Screening
Periodicity
Treatment plans
ANM: VHND/sub-centre/session site
RBSK team: AWC/school
Medical Officer: health facility
RBSK/ANM: as per microplan
MO: opportunistic
 Mild & moderate anaemia
 Severe anaemia

18
First level treatment
• 6–12m (6–10.9 kg):
1 ml IFA syrup
once a day
• 1–3y (11–14.9 kg):
1.5 ml IFA syrup
once a day
• 3–5y (15–19.9 kg):
2 ml IFA syrup
once a day
Follow-up
• Every month by
ANM at VHND
• Monitoring by ASHA
every 14 days
• Hb estimation after
completing 2 months
treatment
No improvement
• Refer to higher
centre for further
investigation
Mild and moderate anaemia (Hb 7-10.9g/dl)
Severe anaemia (Hb <7g/dl) – URGENT referral to higher centre

19
Target group B: 5-9 years
Screening
Periodicity
Treatment plans
RBSK team: screen all children
Children with clinical signs &
symptoms of anaemia – refer to
PHC/SC for Hb estimation
RBSK/ANM: once a year
MO/ANM: opportunistic
 Mild & moderate anaemia
 Severe anaemia

20
• 3mg/kg/day of iron
for 2 months
Follow-up
• Parent Teacher
Meeting for
treatment
compliance
• Parents: ensure
follow-up after 30 &
60 days
• Hb estimation after
completing 2 months
of treatment
No improvement
• Refer to higher
centre for further
investigation

21
Target group: school going (10-
19y)
Screening
Periodicity
Treatment plans
RSBK team: school
Annually
 Mild & moderate
 Severe

22
• Two IFA tablets
(each with 60 mg
elemental iron and
500 mcg folic acid)
• Once daily for 3
months
• Orally after meals
Follow-up
• ANM/LHV/MPHW of
designated area
• Parents: ensure
follow-up after 45 to
90 days at the
nearest sub-
centre/health facility
No improvement
• Refer to higher
centre for further
investigation

23
Target group: PW registered for
ANC
Screening
Periodicity
Treatment plans
Health service provider
 at any ANC contact
 including PMSMA
At every ANC contact
 Mild
 Moderate
 Severe

24
• Two IFA tablets
(each with 60 mg
elemental iron and
500 mcg folic acid)
• Consider parenteral
iron if diagnosed at
late pregnancy or
likely to have low
compliance
Follow-up
• Every 2 months for
compliance of
treatment by health
provider during the
contact
No improvement
• Refer to higher
centre for further
investigation
Mild anaemia (Hb 10-10.9g/dl)

25
• Two IFA tablets
(each with 60 mg
elemental iron and
500 mcg folic acid)
• Consider parenteral
iron if diagnosed at
late pregnancy or
likely to have low
compliance
Follow-up
• Every 2 months for
compliance of
treatment by health
provider during the
contact
• Hb monitoring every
month
No improvement
• Refer to higher
centre for further
investigation
Moderate anaemia (Hb 7-9.9g/dl)

26
• To be done by
Medical Officer at
PHC/CHC/FRU/DH
• Parenteral iron
• Immediate
hospitalization
recommended at 3rd
timester
Follow-up
• Monthly or as
prescribed by
Medical Officer
No improvement
• As prescribed by
Medical Officer
Severe anaemia (Hb <7g/dl)

27
Mandatory provision of iron & folic acid fortified foods in
govt-funded health programmes
GoI mandated use of fortified salt,
wheat flour and oil in foods served
under ICDS & MDM schemes
Health facility-based programmes
where food is being provided are
mandated to provide fortified foods
prescribed and notified by FSSAI

28
Intensifying awareness, screening and treatment
of non-nutritional causes of anaemia
The strategy attempts to intensify awareness and integrate screening and
treatment for following non-nutritional causes of anemia with special focus on
malaria, haemoglobinopathies and fluorosis
• Integration of detection & management of anaemia and
malaria in endemic areas
• Screening for malaria during anaemia screening (PMSMA,
RBSK)
• Indoor Residual Spray (IRS) before & after monsoon
• Promote LLIN utilization via IEC, BCC
Malaria

29
• Quizzes and assisted educative talks
• Screening for haemoglobinopathies
• Appropriate treatment as per National Guidelines on
Prevention and Control of Haemoglobinopathies
Haemoglobinopathies
• Combined approach of safe drinking water and nutritional
therapy (National Programme for Prevention and Control of
Fluorosis)
• Identification of fluoride-affected habitations
• Activities for anaemia control due to fluorosis (counselling,
iron supplement)
• Capacity building
Fluorosis

IODINE
Function Sources
• Synthesis of thyroxine (T4)
and triiodothyronine (T3)
• Essential for normal growth
and development and well-
being of all humans
• Sea foods
• Others: milk, meat,
vegetables, cereals, etc.
• Iodised salt
30
• Essential micronutrient
• Adult human body contains about 50g iodine
• Normal blood level is 8-12 micrograms/dl

IODINE REQUIREMENTS
Category RDA (μg) Category RDA (μg)
Men 150 Infant 6-12m 130
Women 150 Children 1-3y 90
Pregnant women 250 Children 4-9y 120
Infant 0-6m 100 Girls 10-18y 150
• RDA of iodine for adults: 150 micrograms
• During pregnancy (WHO): 250 mcg per day

IODINE DEFICIENCY
GLOBAL
Iodine is one of the most
common nutrient
deficiencies and is
estimated to affect 35–
45% of the world’s
population
INDIA
an estimated 350
million people are at
risk of IDD as they
consume salt with
inadequate iodine
MANIPUR
Goiter prevalence was
31% in 4852 children in
2013
Iodine Deficiency Disorders (IDD) all the effects of iodine
deficiency on human growth and development which can be
prevented by correction of iodine deficiency

Disorders Levels of severity
1. Goitre
– Grade I
– Grade II
– Grade III
– Multinodular
2. Hypothyroidism Varying combinations of clinical sign
3. Subnormal intelligence
Delayed motor milestones
Mental deficiency
Hearing defects
Speech defects
Variable severity
The spectrum of iodine-deficiency disorders in approximate order of
increasing severity

Disorders Levels of severity
4. Strabismus (squint)
– Unilateral
– Bilateral
5. Nystagmus
6. Spasticity (extrapyramidal)
Neuromuscular weakness
– Muscle weakness in legs, arms, trunk
– Spastic diplegia
– Spastic quadriplegia
7. Endemic cretinism
– Hypothyroid cretinism
– Neurological cretinism
8. Intrauterine death
(spontaneous abortion,
miscarriage)
The spectrum of iodine-deficiency disorders in approximate order of
increasing severity (contd.)

Epidemiological assessment of iodine
deficiency
Prevalence of neonatal
hypothyroidism
Measurement of thyroid
function
• Serum T4
• TSH
35
Prevalence of goitre
Prevalence of cretinism
Urinary iodine excretion

CONTROL
36
Nati on al Iod i n e Def i ci ency Di s or d ers Con tr ol P r og r amm e (NIDDCP )
• Bring prevalence of IDD to below 5%
• Ensure 100% consumption of adequately iodized salt at household level
Goal
• Surveys to assess magnitude of IDD
• Supply iodized salt in place of common salt
• Resurveys to assess IDDs and impact of iodized salt every 5 years
• Laboratory monitoring of iodized salt and urinary iodine excretion
• Health Education and Publicity
Objectives
• Iodate the entire edible salt in the country
• Production of iodized salt is 65 lakh metric tones per annum
Policy

ZINC
Function Sources
• Active in the metabolism of
glucose and proteins
• Required for synthesis of
insulin and immunity
function
• Both animal and
vegetable
• Bioavailability of zinc in
vegetables is low
• Animal foods are
dependable sources 37
• Zinc is present in small amounts in all tissues
• Zinc-plasma level: 96pg/100 ml (adult), 89pg/100 ml (children)
• Average adult body contains 1.4 to 2.3 g of zinc

ZINC DEFICIENCY
Adolescents Maternal
• Growth failure
• Sexual infantilism
Severe deficiency
• Spontaneous abortion
• Congenital malformations
Mild deficiency
• LBW
• IUGR
• Preterm delivery
38
• Loss of taste
• Delayed wound healing
Low circulating zinc levels
• Liver disease
• Pernicious anaemia
• Thalassemia
• Myocardial infarct

ZINCSUPPLEMENTATION
Diarrhoea in children Malaria in children
• In combination with ORS
• Significantly reduce duration
& severity
• Increase survival
• Dose:
<6 months old: 10mg/day
≥6 months old: 20mg/day
• May reduce incidence of
clinical attacks
39
Adequate zinc is essential for maintaining integrity of immune
system

ZINC REQUIREMENTS
Category RDA (mg) Category RDA (mg)
Men 17 Children 7-9y 5.9
Women 13 Boys 10-12y 8.5
Pregnant women 14.5 Girls 10-12y 8.5
Lactating mother 14 Boys 13-15y 14.3
Infant 6-12m 2.5 Girls 13-15y 12.8
Children 1-3y 3.3 Boys 16-18y 17.6
Children 4-6y 4.5 Girls16-18y 14.2
• Growing children and pregnant and lactating women need more
• Most human diets provide these amounts

VITAMINA
Function Sources
• production of retinal
pigments which are needed
for vision in dim light
• maintain integrity & and
normal functioning of
glandular & epithelial tissue
• supports growth
• anti-infective
• Animal foods: liver,
eggs, butter, cheese,
whole milk, fish and
meat
• Plant foods: green leafy
vegetables, green and
yellow fruits & roots
• Fortified foods:
vanaspati, margarine,
milk etc 41
• Vitamin A covers both a pre-formed vitamin: retinol, and a pro-
vitamin, beta carotene

Recommended daily allowance
Category RDA (μg) Category RDA (μg)
Men 1000 Children 7-9y 630
Women 840 Boys 10-12y 770
Pregnant women 900 Girls 10-12y 790
Infant 0-12m 350 Girls 13-15y 890
Children 1-3y 390 Boys 16-18y 1000
Children 4-6y 510 Girls16-18y 860
Toxicity
Excess intake causes nausea, vomiting, anorexia, sleep disorders followed by skin
desquamation, hepatomegaly, papillary oedema

VITAMINA DEFICIENCY
43
WHO classification of Vitamin A deficiency (eye signs)
Grade of xerophthalmia Type of deficiency
XN Night blindness Long standing. Not blinding
X1A Conjunctival xerosis Long standing. Not blinding
X1B Bitot’s spot Long standing. Not blinding
X2 Corneal xerosis Acute deficiency. Can be blinding
X3A Corneal ulcer (<1/3) Severe acute deficiency. Blinding
X3B Corneal ulcer/keratomalacia (≥1/3) Severe acute deficiency. Blinding
XS Corneal scarring (from X3) Consequence of corneal ulceration
XF Xerophthalmic fundus Long standing. Not blinding. Rare

Night blindness
Tend to affect women (PW, lactating)
and children 2-6 years
Inability to see in dim light
Worsen if vitamin A intake not
increased

Conjunctival xerosis
First clinical sign of vitamin A
deficiency
Conjunctiva: Dry, non-wettable;
appears muddy & wrinkled
“emerging like sand banks at receding
tide”

Bitot’s spot
usually appear in children 3-6 years
triangular, white or yellowish, foamy
spots on bulbar conjunctiva
either side of cornea, frequently
bilateral

Corneal xerosis
drying of cornea; sign of sudden,
acute deficiency
glands in conjunctiva not functioning
normally
loss of tears & mucous

Corneal ulcer
if acute deficiency not reversed,
cornea become ulcerated
ulcer may appear as small, punched-
out area in the cornea
or, ulcer may have a more fluffy
appearance

Corneal ulcer (contd.)
secondary infection is common

Keratomalacia
most severe form of xerophthalmia
cornea become oedematous and melt
away, due to necrosis
cornea may burst open

End result of corneal ulceration
Corneal scarring
Staphylomas
Phthisis bulbi

EXTRA-OCULAR MANIFESTATIONS
1. Follicular hyperkeratosis
2. Anorexia
3. Growth retardation
Mild deficiency
Increase morbidity &
mortality due to
respiratory & intestinal
infection
52
• They are non-specific
• Difficult to quantify

TREATMENT
Under VPD surveillance
All suspected cases of MR (measles/rubella)
2 doses of Vitamin A given (24 hours apart)
Below 1 year: 1 lakh IU each
1 year & above: 2 lakhs IU each
53
• Vitamin A deficiency should be treated urgently
• 2 lakhs IU orally on 2 successive days
• All children with corneal ulcer should be given Vitamin A,
deficiency suspected or not

PREVENTION &CONTROL
Prevention and/or control takes 2 forms
1. Improvement of people’s diet
2. Reducing frequency and severity of contributory factors
WHO strategy
Short-term action
administration of large
doses of vitaminA orally, in
recommended doses to
vulnerable groups, on a
periodic basis
Medium-term action
fortification of certain foods
with vitaminA
Addition of vitamin A to
dalda is a typical example
Long-term action
reduction or elimination of
factors contributing to
ocular disease
Improve diet &
environment,
breastfeeding,
immunization etc

VitaminA deficiency in India
The programme focusses on
Promoting consumption of vitamin A rich foods by
 Pregnant and lactating women
 Children under-five years of age and appropriate
breast-feeding
55
• National survey among children aged 12–59 months showed
17.54% overall prevalence of VAD in India
• Vitamin A supplementation exists as an integral component of
RCH programme, covering children upto 5 years of age

Administration of massive dose of vitamin A up to five
years
This is done by administering Vitamin A alongside
vaccines under Universal Immunization Programme (UIP)
 First dose of 100,000 1U with measles vaccination at
nine months
 Subsequent doses of 200,000 IU each, every six
months up to the age 5 years
56

For sick children
 all children with xerophthalmia to be treated at health
facilities
 all children suffering from measles to be given one
dose of vitamin A if they have not received it in the
previous one month
 all cases of severe malnutrition to be given one
additional dose of vitamin A
57

Assessment ofVitaminA deficiency
Prevalence criteria for determining xerophthalmia problem
Criteria Prevalence in population at risk (6m-6y)
Nightblindness more than 1 per cent
Bitot’s spots more than 0.5 per cent
Corneal xerosis/ulceration/keratomalacia more than 0.01 per cent
Corneal scar more than 0.05 per cent
Serum retinol (less than 10 mcg/dl) more than 5 per cent
• Prevalence surveys are done on preschool children (6 months to 6 years)
• Presence of any one of the criteria (WHO) should be considered as
evidence of a xerophthalmia problem in the community

Thank you

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