METHODS IN NUTRITION PROGRAMS IN INDIA AND ASSESTMENT OF EXISTING PROGRAM.

NUTRITION DEFICIENCY CONTROL PROGRAMMES

National Prohylaxis Programme for Prevention of Blindness due to vitamin A deficiency.

National anaemia control programme, and National iodine deficiency disorder (IDD)

control programme.

NATIONAL PROPHYLAXIS PROGRAMME FOR PREVENTION OF BLINDNESS DUE TO VITAMIN A DEFICIENCY

Vitamin A deficiency recognizes to be a major controllable public health and nutritional problem.

In India, milder forms of vitamin A deficiency affecting conjunctive,like Bitot spots are observed in about 1-5% preschool children.

According to WHO>0.5% prevalence of Bitot spot in preschool children in indicative of public health significance.

Longitudinal community studies reveal that in some parts of the country, the incidence of corneal xerophthalmia is about >o.5 to 1 per 1000, preschool children.

It is estimated that about 30-40,000 children in the country are at risk of developing nutritional blindness every year.

OBJECTIVES:

The national prophylaxis programme for the prevention of nutritional blindness due to vitamin A deficiency aims at protecting children 6 months- 5 years at risk from vitamin A deficiency.

TARGET GROUP All children, of 6 months to 5 years, particularly

those living in rural, tribal and urban slum areas, are beneficiaries of the programme.

PROGRAMME STRATEGY Prevention of vitamin A

deficiency : The programme comprises a long term and a short term strategy. While the short term intervention focuses on administration of mega dose of vitamin A on periodic basis.

Dietary improvement is the long term ultimate solution to the problem of vitamin A deficiency.

PROMOTING CONSUMPTION OF VITAMIN A RICH FOODS

Regular dietary intake of vitamin A rich foods by pregnant and lactating mothers and by children under 5 years of age must be promoted.

The mothers attending antenatal clinics and immunization sessions as well as mothers and children enrolled in the ICDS programme must be made aware of the importance of preventing vitamin A deficiency.

Breast feeding , including feeding of colostrum ,must be encouraged.

Feeding of locally B-carotene (precursor of vitamin A) rich food such as green leafy vegetables and yellow and orange vegetables and fruits like pumpkin, carrots, papaya, mango, oranges etc. along with cereals and pulse to a weaning child must be promoted widely.

For increasing availability of vitamin A rich food, growing of vitamin A rich foods in home gardens and consumption of these must be promoted.

Administering Massive Dose of vitamin A:

Administration of massive dose of vitamin A to preschool children at periodic intervals is a simple, effective and most direct intervention strategy.

This is a short term strategy. Unlike most other micronutrients, vitamin

A is stored in the body for prolonged periods and hence periodic administration of massive dose ensures adequate vitamin A nutrition.

Under the massive dose programme, every infant between 6-11 months of age and every child between 1-5 years is to be administered vitamin A every 6 months.

6-11 months – one dose of 100000 IU 1-5 years – 200000 IU A child must receive a total of 9 oral

doses of vitamin A by her fifth birthday.

Treatment of vitamin A deficiency

All children with clinical signs of vitamin A deficiency must be treated as early as possible. Treatment schedule includes:

Single oral dose of 200000 IU of vitamin A immediately on diagnoses.

Follow up dose of 200000 IU 1-4 weeks later.

NATIONAL NUTRITION ANAEMIA CONTROL PROGRAMME (NNACP)

Nutritional anaemia is a serious public health problem.

Although anaemia is widespread in the country, it especially affects women in the reproductive age group and young children.

Nutritional anemia, due to iron and folic acid deficiency, is directly or indirectly responsible for about 20 percent of maternal deaths.

Anaemia is a major contributory cause of high incidence of premature births, low birth weight and prenatal mortality.

OBJECTIVES The National Nutritional Anaemia Control

Programme aims at significantly decreasing the prevalence and include of anaemia in women in reproductive age group, especially pregnant and lactating women, and preschool children.

TARGET GROUP The beneficiaries of the programme include: Women in the reproductive age group,

particularly pregnant and lactating mothers. Children 1-5 years of age. Family planning acceptors (women who

accept family planning measures like intrauterine devices (IUD) and tubectomy).

Programme Strategy Promotion of regular consumption of foods rich in

iron. Regular dietary intake of iron and folic acid rich foods

by pregnant and lactating women, adolescent girls and children under 5 years of age must be promoted.

Regular consumption of iron rich foods such as green leafy vegetables (like mustard leaves )(sarson ka sag), amaranth (chaulai sag), colcoasia (arbi) leaves, knol khol greens (ganth gobi ka sag), cereals (such as jaggery (gur) must be promoted widely.

Vitamin C (ascorbic acid) promotes absorption of iron. Regular consumption of vitamin C rich foods such as lemon, orange, guava, amla, green mango along with iron rich foods must be encouraged.

PROMOTING CONSUMPTION OF IRON AND FOLIC ACID SUPPLEMENTS TO THE ‘HIGH RISK’ GROUPS

Pregnant Women: One big (adult) tablet per day for 100 days (each tablet containing 60 mg/ 100 mg of elemental iron and 500 ug folic acid). These tablets to be provided to women after the first trimester of pregnancy.

Preschool Children (1-5 years): One paediatric (small) tablet containing 20 mg iron and 100 ug folic acid daily for 100 days every year.

Lactating women and IUD acceptors: One big (adult) tablet (containing 60mg/ 100 mg of elemental iron and 500 ug folic acid) per day for 100 days

INDIVIDUAL AND POPULATION-BASED ASSESSMENT 

Surveillance of iron deficiency involves an ongoing process of recording and assessing iron status in an individual or a community.

Worldwide, the most common method of screening individuals or populations for iron deficiency involves determining the prevalence of anemia by measuring blood hemoglobin or haematocrit levels.

A major limitation of each of these two tests, however, lies in the fact that anemia is not a specific indication of iron deficiency. Other nutrient deficiencies and most infectious diseases can also result in significant anemia.

One common practice in assessing whether or not anemia is due to iron deficiency involves monitoring the response in hemoglobin or haematocrit levels after 1 or 2 months of oral supplementation with iron.

An increase of 10 g/l in hemoglobin or 3% in haematocrit is indicative of iron deficiency.

Individual management in resource-poor countries is likely to be based mainly upon either hemoglobin or haematocrit assessment - or both - and upon their response to initial iron therapy.

PURPOSES OF BIOLOGICAL ASSESSMENT 

Determine the magnitude, severity, and distribution of iron deficiency and anemia, and preferably its main causes.

Identify populations more affected or at greater risk

Monitor trends in prevalence and evaluate the impact of interventions

Measure progress towards achieving the goals adopted by the International Community.

Provide the basis for advocacy programmes for iron deficiency and anemia prevention in affected and vulnerable populations.

NATIONAL IDD CONTROL PROGRAMME  Elimination of Iodine Deficiency Disorders

(IDD) is a most important health and social goal.

Iodine deficiency at critical stages during pregnancy and early childhood results in impaired development of the brain and Consequently in impaired mental function.

There are three major components of sustainable programme to eliminate IDD: political support, administrative arrangements, and assessment and monitoring systems

There are three major components of sustainable programme to eliminate IDD:

political support, Administrative arrangements Assessment and monitoring systems.

Recognizing the importance of preventing IDD, the World Health Assembly

Adopted in 1991 the goal of eliminating iodine deficiency as a public health

Problem by the year 2000. In 1993, WHO and UNICEF recommended universal

salt iodization (USI) 1 as the main strategy to achieve elimination of IDD.

MONITORING AND EVALUATING IDD CONTROL PROGRAMMES

Monitoring of any health intervention is essential, to check that it is functioning as planned and to provide the information needed to take.

Salt iodization programmes, like any other health interventions, therefore require an effective system for monitoring and evaluation.e corrective action if necessary.

The challenge is to apply the IDD indicators using valid and reliable methods while keeping costs to a minimum.

INDICATORS WHICH ARE USED IN MONITORINGAND EVALUATING IDD CONTROL PROGRAMMES.  Process indicators These indicators involve salt iodine content

at the production site, Point of packaging, wholesale and retail

levels, and in households. Indicators to assess baseline IDD status and

to monitor and evaluate the impact of salt iodization on the target population (impact indicators)

Sustainability indicators This involves a combination of median

urinary iodine levels in the target population, availability of adequately iodized salt at the household level.

Recommended iodine intake WHO, UNICEµF, and recommend that the

daily intake of iodine should be as follows: 90 µg for preschool children (0 to 59

months); 120µg for schoolchildren (6 to 12 years); 150µg for adults (above 12 years); and 200µg for pregnant and lactating women.

ADMINISTRATIVE ARRANGEMENTS Assessment of the situation requires baseline IDD

prevalence surveys, including measurement of urinary iodine levels and an analysis of the salt situation.

Dissemination of findings implies communication to health professionals and the public, so that there is full understanding of the IDD problem and the potential benefits of elimination.

Development of a plan of action includes the establishment of an intersectional task force on IDD and the formulation of a Strategy document on achieving the elimination of IDD.

political will requires intensive education and lobbying of politicians and other opinion leaders.

Implementation needs the full involvement of the salt industry.

Special measures, such as negotiations for monitoring and quality control of imported iodized salt, will be required.

It will also be necessary to ensure that iodized salt delivery systems reach all affected populations, including the neediest

Monitoring and evaluation require the establishment of an efficient system for the collection of relevant scientific data on salt iodine content and urinary iodine levels.

 

ASSESSMENT It is necessary to provide adequate dietary iodine to

prevent brain damage in the fetus and in the young infant when the brain is growing rapidly.

Whether or not a national programme is providing an adequate amount of iodine to the target population is reliably assessed by reference to measurements of salt iodine (at the factory, retail, and household levels) and urinary iodine (measured in casual samples from schoolchildren or households).

Additional contributive measurements are estimation of thyroid size and blood tests.

Measurements of salt and urinary iodine thereby provide the essential elements for monitoring whether IDD is being successfully eliminated.

MONITORING SYSTEMS

External monitoring systems by governments-This system are based upon the establishment of a law which mandates that all salt for human and - in most countries, animal - consumption is iodized.

Other legal requirements should include packaging in polyethylene bags, labeling to identify the iodine level and the name and address of the company Packaging the salt.

Internal monitoring systems by producers and distributors

The Ministry of Industry, the Bureau of Standards, or Codex Alimentarius are useful reference sources for guiding producers in the process of iodizing salt.

IMPLEMENTATION STRATEGY The NIDDCP is executed by a multiplicity of

agencies comprising the Health, Industry and railway ministries of the central government.

The ministry of health and family welfare and directorate general of health services (DGHS) is responsible for the national implementation of the programme.

The salt department, under the ministry of industry, is the nodal agency for production, distribution , monitoring and quality control of iodised salt.

The salt commissioner, in consultation with the ministry of railways, arranges for the movement of iodized salt from the production centre to the states.

The state government is responsible for the distribution of the iodized salt within the state either through the public distribution system or through the open market

CLINICAL EXAMINATION

Clinical examination assess levels of health of individuals or of population groups in relation to the food they consume.

It is the simplest and practical method. When two or more clinical signs

characteristic of a deficiency disease are present simultaneously, their diagnostic significance is greatly enhanced.

CLINICAL SIGNS AND SYMPTOMS OF NUTRITIONAL INADEQUACYSITE SIGN DIFICIENCY

General Appearance Loss of subcutaneous fat

Sunken or hollow cheeks

Calories

Calories, fluid

Hair Easily plucked hair, alopecia

Dry, brittle hair

Corkscrew hairs

Protein

Protein, biotin

Vitamin C

Nails Spooning

Transverse depigmentation

Iron

Protein

Skin Dry and scaly flaky paint

Nascolabial seborrhea

Psoriasiform rash

Pallor

Follicular hyperketatosis

Easy brusing

hyperpigmentation

Vitamin A, zinc

Essentialfatty acid, riboflavin

Vitamin A, zinc

Iron, Vitamin B12, folate

Vitamin A, essential fatty acid

Vitamin K and C

Niacin

Eyes Night blindness

Photophobia, xerosis

Conjunctival

inflammation

Retinal field defect

Vitamin A, zinc

Vitamin A

Riboflavin, Vitamin A

Vitamin E

Mouth Glossitis

Bleeding gums

Angular stomatitis

Decreased taste or smell

Tongue fissuring

Tongue atrophy

Loss of teeth enamel

Riboflavin,pyriodoxine,

niacin folic acid, Vitamin B12,

Iron.

vitaminC, riboflavin.

Riboflavin pyridoxine,niacin.

Zinc

Niacin

Riboflavin pyridoxine,niacin

Calcium

Neck Goiter

Parotid enlargement

Iodine

Protein

Heart High output failure Thiamin

Chest Respiratory muscle weakness Protein, phosphorus

Abdomen Ascites

Hepatomegaly

Protein

Protein, fat

Extremities Edema

Bone tenderness

Bone/ joint pain

Muscle pain

Joint swelling

Protein

Vitamin D

Vitamin A or C

Thiamin

Vitamin C

Muscles Atrophic muscles

Decreased grip strength

Protein

Protein

Neurological Dementia

Acute disorientation

Nystagums

Peripheral neuropathy

Loss of vibratory sense

Loss of position sense

Tetany

Wrist of foot drop

Thiamin, Vitamin b12, folate,

Phosphorus, niacin

Thiamin

Thiamin,vitamin E

Vitamin B12

Vitamin B12

Calcium, magnesium

Thiamin

ADVANTAGES OF CLINICAL ASSESSMENT: Physical examinations should be an integral part of

most nutrition surveys for the following reasons: It is inexpensive. It does not require any laboratory equipment. A physical examination may reveal evidence of certain

nutritional deficiencies which will not be detected by dietary or laboratory methods.

The identification of even a few cases of clear-cut nutritional deficiency may be particularly revealing and provide a clue of malnutrition in a community.

The nutritional examination may reveal signs of a host of other diseases which merit diagnosis and treatment.

DISADVANTAGES OF CLINICAL ASSESSMENT: The major problems encountered in the clinical

assessment of nutritional status are: These have a low general prevalence in

developed countries except in high risk groups. Some clinical signs are non-specific of

nutritional deficiency. One clinical sign overlaps for more than one

deficiency disorder. It does not reflect the magnitude of the

problem. Skilled personel is required to carry out clinical

examinations. 

BOICHEMICAL TEST

BIOCHEMICAL TEST

Variations in the intake of different nutrients present in the diet are reflected by changes in the concentration of the corresponding nutrients or metabolites influenced by the nutrients, in blood, tissue and in urine.

Although biochemical estimations of nutritional significance can be carried out on a variety of body tissues, including liver, muscle and bone, in practice, in field surveys, tests are confined to 2 fairly easily obtainable body fluids: blood and urine.

The accuracy of biochemical tests depend upon the standards of collection, methods of transport and storage, including possible exposure to ultraviolet light, heat and shaking as well as the actual technique used.

The important biochemical methods useful in the detection of nutritional deficiency states are classified under 2 heads:

First category methods: which include tests which are fairly simple to perform and have been widely used for detection of nutritional deficiency states

Second category methods: which are more complicated for use as routine procedures, but can be used by institutions having adequate facilities

TYPES OF BIOCHEMICAL TEST Measurement of nutrients, metabolites or

other products in blood or urine. Measurement of activity of vitamin dependent

enzymes in RBC’s and in vitro activation with corresponding coenzymes. E.g. glutathione peroxidse.

Measurement of accumulated metabolites whose disposal depends upon vitamin or mineral dependent enzymes without preloading with precursor.

Measurement of some end function like RBC fragility, blood clotting, tensile strength of skin, work capacity etc.

BIOCHEMICAL METHODS FOR ASSESSING NUTRITIONAL STATUS

Nutrient Principle Method Normal Deficiency

Vitamin A S. vitamin A

Relative Dose Response

test

(450- 1000 ug retinol)

Dehydroretional :

(vitamin A )₂

30 ug/dl

-

-

< 20 ug/ dl

>20% RDR

> 0.06

Vitamin D S.25-hydroxyl

cholecalciferol

>10 ng/ml <5 ng/ml

Vitamin E S. vitamin E/total lipid

ratio

>0.8 -

Vitamin K Protein induced by

vitaminK

absence PIVKAS

Absent Accumulate

Thiamin Urinary thiamin.

Erythrocyte

Transketolase test

(ETK-AC)Activated

coefficient

>100 ug/ 24 hr

>65 ug/g of creatinine

<1.15

-

>1.25

Riboflavin Erythrocyte-glutathione

reductase (EGR-AC)

< 1.2 >1.4

Niacin N- methy 1-2 pyridone –5

carboxylamide

(2- pyridine) and

N1- methyl nicotinamide

ratio

1-4 <1.0

Vitamin B6 Erythrocyte

asparatate amino

Transferase (EAspAT- AC)

<1.7-2.0 _

Folic Acid Serum folate

RBC folate

Formimino glutamic acid

FIGLU

> 6.0 ng/ml

> 160 ng/ml

< 20 mg FIGLU in 8 hours

after histidine load of 0.26

g/kg body weight

<3.0 ng/ml

< 140 ng/ml

>100 mg

Vitamin B12 Serum B12 200-900 pg/ml 80 pg/ml

Ascorbic Acid P. ascorbic acid levels

Leucocyte ascorbic acid

>0.3 mg/dl

>15 mg/dl

< 0.2 mg/dl

< 8 mg/dl

Iron Serum feritin levels

Serum iron

Serum transferring

Haemoglobin

-

-

-

>13 g/dl (Men)

>12 g/dl (Women)

<12 ug/l

< 40 ug/dl

<0.16

-

-

Iodine Urinary excretion of

Iodine

>50 mg/g creatinine -

Zinc P. zinc 84-104 ug/dl -

Copper S. copper 75-125 ug/dl -

PROTEINS The tests available to determine

protein status include serum albumin, serum transferring, other serum proteins and total lymphocyte count and other tests of immune function.

Of these, serum albumin and serum transferring are commonly used.

Serum albumin: albumin counts for 50% of total serum proteins. It helps maintain fluid and electrolyte balance and transport many nutrients, hormones, drugs and other compounds. Albumin conc. reflects protein status of blood and internal organs.

Serum albumin conc. tend to decline slowly because it can shift from the cells to the blood when blood levels fall.

Additionally, because albumin breaks down slowly, it is slow to reflect changes in nutritional status. Therefore, low serum albumin levels represent prolonged protein depletion.

Serum transferring: it is a protein that transports iron between intestines and site of Hb synthesis and degradation.

It is a more sensitive indicator of protein malnutrition than serum albumin because it responds more rapidly to changes in protein intake.

Total lymphocyte count: TLC is reduced in protein malnutrition. So it is a useful index in nutrition assessment .WBC volume and red blood cell counts are routinely measured through which TLC can be easily calculated.

Nitrogen balance: nitrogen balance studies help to estimate degree to which protein is being depleted or repleted in body.

Simple approach to measure nitrogen is to measure urinary urea nitrogen (UUN) in 24 hr urine collection. Nitrogen balance studies are invalid if even one urine sample is flushed or one meal’s protein intake is not accurately recorded.

Creatinine in urine: skeletal muscle is depleted during protein deficiency. Muscle mass is related to the excretion of creatinine in urine. Studies show that excretion of creatinine in urine in 24 hrs expressed per cm. body height is a good index of muscle mass in children.

Urea/creatinine in urine: the quantity of urea excreted in urine is related to protein intake, while the quantity of creatinine excreted in urine is not related to protein intake but is fairly constant for the individual.

Creatinine excretion is proportional to muscle mass in the body. Studies on children show that the urea/creatinine ratio is lowered to a significant extent in children suffering from malnutrition.

Iron: iron deficiency is the most widespread mineral deficiency. Although other tests are more specific in detecting early deficiency, Hb and Heamatocrit are commonly available tests.

Haemoglobin: iron forms integral part of Hb molecule that transports oxygen to cells. In iron deficiency, body cannot synthesise Hb. Low Hb values indicate depleted iron stores.

The only disadvantage is that because Hb conc. drops fairly late in development of iron deficiency and because other nutritional deficiencies and medical conditions can also alter Hb conc., its uefulness is limited.

Haematocrit: it is the percentage of RBC in total blood volume. It is commonly used to diagnose iron deficiency. Low value indicate incomplete Hb formation which is manifested by microcytic, hypochromic RBC.

ADVANTAGES OF BIOCHEMICAL TESTS Can be measured with high specificity and

sensitivity. These have excellent accuracy and objectivity. These are non invasive in nature. These can give us an early warning of impending

problem. These represent integral effect of dietary intake of

nutrients from food and supplements over a period of time.

Different types of index for each nutrient can specifically reflect either recent nutritional intake or long term intake and status.

Unlike clinical signs and symptoms of deficiency disease, biochemical markers are nutrient specific.

Rapidly and predictably responsive to correction of nutritional deficiencies.

DISADVANTAGES OF BIOCHEMICAL TESTS

These are expensive tests. They can only be performed by using

laboratory equipments and hospital facilities. Age, sex, community differences are not

included. These are time consuming tests. These tests require trained and skilled

personnel. There are uncertain “standards” for less

advanced forms of malnutrition, especially in young children.