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RF_NUT_4_A_SUDHA
4
VITAMIN K
Coagulation vitamin
Vitamin K acitivity is shown by Tjitamin K2 vitamin KI and menadione.
Menadione is at least three times as potent as vitamin K.
Measurement
In mgms or mcg - ability to prevent haemorrhage in young chick.
Menadione is used as standard.
Physiology;Vitamin K is necessary for production .to prothromt in which
converted to thrombin which is itself necessary for formation of fibrin.
Bile salts are essential for absorption.
Storage is negligible, but
most of it is stored in liver.
Daily allowance
Is not yet established.
May be 1 - 2 iyg.
Sources:Green leaves of alfa'fa, sinach, cabbage, cauliflower pork liver.
Bacterial action in intestine responsible for synthesis of vitamin
K. is body.
Heficiepgy:Generally not known.
In a new bom infant vitamin K in intestines
is not established for a week or so following birth, therefore infant
is susceptible to haemorrhagic disease.
To prevent this vitamin K
1 mg per day is given to pregnant women during the last month of
pregnancy.
Deficiency may also result from oral therapy with sulpha
drugs and antibiotics over a prolonged period,
with intestinal flora.
because they interfere
Severe diarrhoea, sprue, coaliac disease,
severe ulcerative colitis interfere with absorption of vitamin K
leading to tendency for haemorrhage.
When there is insufficiency bile
salts, menadione is administrated with bile salts.
Vitamin K administered during liver damage is fwitabie because
absorption
then is adequate.
n#*n ii mt n**n
VITAMINS
Introduction
A polish chemist Funk, first coined the term
*Vitamine", thereby meaning Vital amines.
The final 'e8 was soon dropped. Vitamins
now describe a group of pat/ent organic
compounds other than proteins, fats and
carbohydrates. They occur in minute
quantities in foods and are essential for
some specific body functions of maintenance
an£.growth.
Classification
1.
2.
Water soluble vitamins,
Fat soluble vitamins.
Measurements:nature
Before the chemical/of vitamins was discovered,
potency was measured ohly by their ability to
promote growth or to cure a deficiency when
test dose were fed to experimental animals.
Thus measurements is known as 'bioassay’ and
is expressed in terms of units. Vit. A & D
are still .measured in international units i.e.
U.
I.
Other vitamins are measured by 'chemical
assay' and' expressed in milligrams....or microgram'
e.,
i.
mg or mcg. 1 mg = 1000 mcg or gammer.
"Microbiologic assay" is that method by which
vitamins are measured by their ability to
promote growth of microorganisms.
Supplementa tion sOf diet with Vitamins is essential when:1.
a diet is severely deficiency in vitamins
through ignorance or poor eating habits.
2.
during growth, pregnancy and lactation.
3.
when absorption is impaired.
Fat soluble vitamins.
VITAMIN A
was the first fat soluble vitamin to be
Vit. a
In
discovered.
some ways, it is related to chloropjryll l.e., the green colouring
Carotene which is a precursor of Vit. A, occurs
matter of plants.
abundantly in the dark green vegetables and in yellow vegetables and
fruits.
Characteristics
In its pure form Vit. A is a pale yellow crystalline compound
which occurs naturally and can also be synthesized chemically.
soluble in fats but insoluble in water.
heat, acids and alkalies but is easily oxidized.
prevented to a great extent by Vit. 13.
It is
It is relatively stable to
Oxidation is
The ultimate source of all
,
■eitamin A is in carotene which is synthesized by plants and converted
to vitamin A by man.
Msasurenient;Is done by biological assay and chemical assay and expressed as
International units.
I. I.U = Vit. A activity of 0.344 mcg of pure
vitamin A accetate.
Physiology:-
Vit. A is more rapidly absorbed than carotene.
Bile is.essential
for absorption of carotene but not of vit.A. _ Absorption is facilitated
(fc
by faets.
tkevevcZe- cUxctr
v-vot,
Ao-c-ba-oXo
Once absorbed and finally empties into general circulation.
Factors:Interferring with fat absorption will also interfere with absorp
tion of vit. A.
e.g., mineral oils taken immediately after meals.
Body has a great capacity to store vit. A.
95$ of vit. A is stored
in liver.
Functions
1.
All vitamins are essential for growth.
Vitamin A is specially
needed for skeletal growth and normal tooth structure.
2.
Maintenance of normal vision in dim light vitamin A and protein
- Rhodopsin (Visual purple which is essential for vision in dim
light).
Visual purple and light - retinine and protein vitamin
A is essential for complete and rapid regeneration of rhodopsin
.2
3
deficiency,
i.e., Nyctalopia - inability to see well in dimlight eg.,
on entering a darkened theatre.
For diverse, this is a great hazard.
Rests are dark adaptation test with biophotometer, blood carotene and
iTtfc1 vitamin A level apart from dietary history,
2.
Epethelal changes: are marked throughout the body.
hardening and degenerations of cells, i.e. Keratinzation.
ibility to infections is thereby increased.
Shrinking,
Suscept
Mucous membranes of eyes
nasal passages, middle ear, lungs, and genitourinary tract are affected.
Sking changes - skin becomes dry, rough, scaly, Keratinized
epithelium - plus sebaceous glands, to cause goose - pimple like
follicles, appear on forearm, thighs, buttocks, shoulder, back and
abdomen.
Eyes:- may be affected varying from mild to severe and irrever
sible changes. Photophobia, itching, burning, inflammation of lids,
dryness of eye and eyelids from impairment of glands i.e. ke^mal^
Xerophthal imia may result.
leading to ulcertation.
infection.
Cornea is dry, inflammed, Oedematous
Absence of lacrymal secretion favours
Finally Keratomalacia sets in with permanent blindness.
PX£y.bn.t iPh- flfld.. treatment: 1.
recommended daily allowance necessary.
2.
remove or cure conditions interferring with effective utilizatio
n of food.
3.
prescribe therapeutic dose of vitamin A i.e. 25,000 to 50,000
I.U. daily.
fiyperitaminosls:May be due to digestion of an azcess of 50,000 I.U. over a prol
onged period causing:-
1.
loss of appetite.
2.
Dryness and cracking of skin.
3.
Swelling and pain in long bones.
4.
Bone fragility.
5.
Enlargement of (M-vert- spleen.
UaWV'
***4.*^*
2
3.
Vitamin A is essential for intergrity of epithelium especially
of mucous membrane which line eyes, mouth, glands, gastro
intestinal tract and genitourinary tract.
4.
In experimental animals normal reproduction and lactation cannot
take place without vitamin A.
Bally. allpwans? *-
3000 I.U. of Vit. A for adults
6000
"
1500
"
for infants
5000
"
for children
of carotene
6000 - 8000 I.U.
for pregnancy and lactation.
Food sources:-
Breen leafy vegetables:e.gu Spinach, turnip, tops beet, greens.
Yellow vegetables:-
e.gi carrots, sweet poratoes, pumpkin.
Yellow fruits
e.g. Apricot, peaches.
Animal. spprpeg.:-
e.g. Fish liver oils, milk, butter, fortified
margarine, whole milk cheesem liver egg yolk.
1 Egg provides l/10th daily allowance.
Vitamin A is stable at usual cooking temperatures.
Long, slow
cooking is detrimental to vitamin A. simly - dehydration and rancidity of
fat affect it adversely.
Canned and frozen foods retain vitamin A value for 9 months or
even longer.
PeficA.encyi-
Of vitamin A result from inadequate intake, faulty absorption eg.
chronic diarrhoea, sprue, liver disease, pancreatic dysfunction and use
of mineral oil immediately after meals eg. liquid paraffin.
Syjaptjama:1.
Night blindness: is one of the earliest signs of vitamin A
...3
/
VITAMIN D
' 7 ' r<
Vitamin D is chemically a distinct sterol compound possessing
Antirachitic properties.
In pure form it Is white, odourless crystal,
l
li
Ua. kAo&'CZeilL.
soluble in fats and fat solvents, but insoluble in lalkalies and
F
oxidation.
Precursors
1. Vitamin D2 (Calciferol) is found in plants.
2. Vitamin D3 (Activated 7) dehydrocholesterol occurs in fish
liver oils and develops in skin on exposure to ultravioletrays.
Phvsiolfigx! -
Man can syntenesize provitamin D3 in the body.
place in the skin of exposure to U.V.R.
Activation takes
Vitamin D3 from skin and
vitamin D2 from diet are steres mainly in liver.
Body tonserves vitamin
D carefully.
■Measurement; -
Rachitic rats are used.
on diet.
They are borne of rat mothers fed rachitic
They are also fed rachitiz diet.
place at ends of long bones.
Np calcification takes
Then measured amount of vitamin D is
fed for 7-10 days to produce a good calcium line in ends of long bones.
This is calcium line test.
1 I.U. of vitamin D = activity of 0.25 mcg of pure crystalline
vitamin D.
Functions:Vitamin D Begulates absorption
and anchorage of calcium and
phosphorous by:(i) rendering intestinal mucosa more permeanle to calcium
salts and also
(ii) by regulating level of alkaline phosphate in serum
therby governing deposition of calcium phosphate in bones
and teeth, i.e., maximum utilization of calcium is
assisted.
Daily allowances
Need is small for adults.
Those not exposed to sufficient sun
light, adolescent children, pregnant and particularly the Muslim
women who observe purdha system, lactati-pij woman, premature infant and
also, underdeveloped Infants need 400 I.U. of vitamW-D for building of
new skeletal tissue.
Sources
Natural foods are poor sources of vitamin D.
Small amount is present in
egg yolk, liver, and fish egherring, sardine, tuna and salmon fish liver oils,
cold liver and halibut oil also contain vitamin D.
Sunlight cannot always be
depended, upon to supply the body with adequate U.V.R. for synthesis of vitamin D.
Because, these rays are easily strained out by dust, fog, smoke, clothing and ordin
Fortification of milk i.e. 400 I.U./quart of milk could be an
ary window glass.
ideal solution because milk is consumed by growing children and becauseit contains
calcium and. phosphorous whose utilisation it favours.
Deficiency:- Occurs vhonthcre is prolonged insufficient intake of vitamin D or in
dark, overcrowded, section of cities where eunshine cannot penetrate through fog,
smoke, and soot,
Dark skinned individuals are more susceptiblies than those with
shite skin.
2. Tetany, 3. Dental caries, 4. Osteom
alacia.
dxu.
and
Deficiency of vitamin Dxtc inadequate absorption of calcitim/phosphorous
Manifestations are:-
Rickets:-
from the intestine.
results.
1. Rickets,
Thereby faulty mineralisation of bone and tooth structures
Thus, the inability of soft bouesto withstand stress of weight leads to
skeletal malformation.
Afully developed ca/so of ricket shows:1.
Delayed closure of fontanelles softening of skull, i.e., cranobabes bossing
of the forehead hotcross bun.
2.
Soft fragile bones which are widened at ends of long bones.
Bowing of legs
and enlargement of costechondral junction results in rows of knobs resembling
(IS t b-Jl]
beads:- called Rectiflc rosary. Projection of the sternum produces pigeon breast.
There is also depression of ribs and narrowing of pmlvis apart from kyphosis.
3.
Enlargement at wrists, ankles and knees may be manifested as knook knees.
4.
POORLY developed muscles and lack of muscle tone produces, (pot belly formation),
There is also delayed, walking.
5* Restlessness and nervous irritability.
6. Low xgxaxxniE igs inorganic blood phosphorous with high secum phosphatase.
II
Tetany:1.
Results from abnormal calcitup $nd pueemofous metabolism due to
failure cf absorption of calcium or vitamin D.
ii.
insufficient dietary calcium and vitamin D,
iii.
from disturbance of parathyroids.
...3
3
Symptoms:- Shart flexion of wrists and ankle joints, muscle twitching, cramps and
.
e <a •.
- ’• ’■
;
Treatment?- Calcium for acute spasons liberal diet/ in calcium and vitamin D.
concentrate.
III
<A«Ax£Ltlovi
Dental carries;- Delayed
malformation of teeth and predisposition of
dental carries.
Osteomalacia:-
IV
Is adult rickets which results from failure of calcification in
respect of other metabolic processes,
Caused by lack of vitamin D and clacium.
Also, possible when there is interference with fat absorption.
One third of cases
may be due to inherent resistance to vitamin D,
This is specially common in our women whe are pregnant or lactating and who are
indoor most of the time, also among Muslim women who observed ’purdha*.
Saap-tomLi)
softening of bones - so severe as to produce deformities specially in bones of
legs, spine, thorax and pelvis.
ii)
iii)
pain of rheumatic type in bones of lags and lower part, of back.
general weakness specially difficulty in climbing skiixs
stairs, patients
haswaddling gait.
iv)
spontaneous multiple fractures.
Treatment?- High protein and high caloric diet. Therapeutic doses of vitamin D.
Hynervitaminpsj.s;-
Nausea diarrhoea weightless, polyruda nocturia, fatigue, renal
damage, calcification of soft tissues, eg., heart, blood vessels, bronchi, and
tubules of kidneys.
HEALTH
AND
NUTRITION
VMUT' 4-
EDUCATION
An opinion questionnaire on some basic concepts
by Dr. S„ Zellecks, Health Educator, WHO, Entebbe, Uganda
The following statements are designed to find out your personal opinions about
various aspects of health education. Although some of them may be contraversial, you
should feel free to respond to each question without considering this to be a form of
examination. Please note the following points:
(1)
You should check 'Agree' if you accept the statement as it stands, 'Doubtful' if
you feel you cannot express an opinion at this' time, and 'Disagree' if you feel the
statement as it stands should be changed even in minor respects.
; (2)
For better understanding of the basic concepts in Health Education, there will be
a discussion period based on your responses to the statements after you return the
second copy duly completed.
.
Your name or signature will not be required.
' Agree
1.
A person's knowledge, experience, attitudes and beliefs are
responsible for his behaviour.
2.
Opinion-leaders are people with more knowledge and ideas than
others.
J.
In a community where the behaviour of the individual or group
adversely influences the state of health, it is imperative to
enlist the active co-operation and participation of the
community in all activities aimed at improving its health
standards. When such is the case, emphasis should be given to
those activities directed at inducing favourable changes in
the health behaviour of the individual or group.
4.
The more we can teach people about health, the healthier they
are likely to become.
5.
In any given society the most effective way of influencing
favourably the health behaviour of the individual and/or
group is through health education — the application of the
principles and methods involved in the educational process.
6.
The aim of health education is to make everyone thoroughly
health' conscious.
7.
The best way to educate a large population in health matters
is with mass media.
8.
There is an educational aspect to the duties and responsibi
lities of all health and allied workers in the performance of
their daily tasks.
9.
It is necessary that all health and allied workers undertake
adequate theoretical and practical training in the principles
and methods of health‘education in'order to be able to dis
charge effectively the educational components of their
respective duties and responsibilities.
Doubt- Disful
agree
2
Agree
10.
In any given community the group which is likely to be most
effective in instigating favourable changes in health
behaviour through health education should be the team of
health and allied workers directly engaged in that community.
11.
To ensure a high degree of receptivity for a learning
situation, it is very useful to inject an atmosphere of
entertainment in that situation.
12.
The solution to a given health problem is the same in all
communities.
1J.
Health education is essentially the same as health propaganda
or health information or health instruction.
14.
In health and nutrition education one must constantly bear
in mind the economic factor and always remember the fact
that, in general, the families whose nutritional needs are
the greatest are usually also the ones who have the least
means for buying what they need.
15.
Lay persons and community members should take part in the
planning of health programmes at all levels.
16.
Nutrition education activities, as in health education,
must be part of the national policy and plans adapted to
local conditions. This should include establishment of
a service unit centrally located within an appropriate
Ministry and organized in a manner to enable it to assume
the direction, supervision and evaluation of its field
activities on a national scale.
17.
That Africans do attach a high value to their health is
indicated by the fact that in many languages the greeting
and/or farewell expressions are wishes of good health.
18.
Health education is concerned with the promotion of health
and the prevention of disease and not 'with curative work.
19.
Nutrition and education has sometimes been the subject of co
operation between government departments as well as several
specialized agencies of the UN. This approach should be
continued and intensified.
20.
Health and nutrition education of the child must be an
integral part of general education rather than a special
suject taught during a specific hour.
21.
The common dish where the meal is shared by a group or
family, should be discouraged as an udesirable practice on
grounds of hygiene.
22.
A survey of knowledge of the psycho-sociological and cultural
ways of life of a community is an absolute pre-requisite for
undertaking health and nutrition education in that community.
Doubt- Disful
agree
1
2JO
If T&jo or more of the people in a community see a health
education film, then this is a successful use of that film.
24.
In health education for the general public, one must set out
the health facts clearly and in logical order.
25.
Health and nutrition education in the context of a developing
society is more effective if the ’aristocratic ’ approach is
used. This means winning first the support and co-operation
of these who are in a position of authority or influence in
the community.
Hon-medical healers and curers indigenous to the community
should be prohibited from practice.
27^^ The best methods of health education are face-to-face,
26.
inter-personal methods.
28.
In health and nutrition education, the starting point is
from the existing attitudes, beliefs, and practices of the
community in question.
29.
In order to avoid confusion, community members should not
be involved in programmes until the medical and health
experts have made up their minds about what is needed.
30.
The most important point in nutrition education of the
general public is to identify the smallest changes which
can be introduced in the traditional dietary practices for
maximum improvement. This should be followed by teaching,
with the utmost clarity and simplicity, the value of these
changes as well as the manner in which they can be effected
successfully .
51. Learning will occur mostly when and where people want to
A learn.
32.
Nutritional problems can be solved through a dynamic effort
in health education even in the absence of services for
curative as well as prophylactic counter-measures.
33.
Human behaviour is one of the important factors which
determine the state of health of the individual, family
and community.
34.
Health education may be defined as the teaching of health
facts so that people may look after their health better.
35.
The most competent person to do health education is the
doctor.
36.
It is extremely difficult to inspire with a sense of
urgency a population affected by malnutrition and to spring
them into action for the appropriate preventive measures.
This is partly due to the fact that malnutrition usually
occurs in chronic evolution rather than in spectacular
epidemic.
4
l|
!! Doubt- 1 Dio■ ■ Agree
ful
agree
37,
Poor comniunjties with relatively heavy disease loads need
medical services and facilities rather than health education.
58.
Many people do not have the intelligence to profit from
health education.
59.
Once people are shown how reasonable a suggestion is, they
usually follow it.
40.
Better health is the basis for greater productivity and
improved national economy.
/Mu |
C. R. RAMACHANDRAN
NNT ' <+•
Vernier Tape for Circumferential Measurements
by C. R. Ramachandran
Deputy Director General, Indian Council of Medical Research, Ansari Nagar, New Delhi-110 029, India
Mid-arm circumference has been one of the most
widely used indicators for the assessment of nutri
tional status especially during childhood because the
tape is an inexpensive and readily portable instrument
and measurement of this parameter is easy and sim
ple.'■2 In the last few years there has been a trend to
provide the tape to non-nutritionists for screening ‘at
risk’ neonates, infants and children in rural popula
tion in developing countries.3"’ The non-nutritionists
may not be well-versed in the use of the tape and so
the tape has to be so designed that measurements are
replicable in their hands. Some investigators have
advocated the use of mid-arm circumference as an in
dicator for assessment of improvement in nutritional
status especially following nutritional supplemen
tation. This necessitates greater precision because the
differences in the measurement before and after sup
plementation are likely to be no more than a few milli
metres. There is, thus, a need to redesign the tape to
obtain greater precision and replicability in circum
ferential measurements. Defining the problems with
the currently existing tape and currently used tech
niques for circumferential measurement is an essential
pre-requisite for attempts to improve the design of the
tape or technique of measurement.
subtractions of this nature may pose problems in the
hands of field workers. It is thus essential that in the
improved design of the tape, marking should begin 23 cm away from the end of the tape so that the tape
could be comfortably held.
One of the crucial factors in accurate measurement
of mid-arm circumference is the snugness of the fit.
The tape should be firmly held against the skin but
not crimp the skin. Most nutritionists develop a ‘feel’
for this. But the less-trained observers tend to tighten
the tape until the skin crimps. If it is stressed during
their training that the tape should not be held too
tight against the arm, they wind the tape loosely so
that a small space is left between the tape and the arm,
especially where the tape crosses over. These two pro
cedures can lead to errors of up to 2-3 mm. Providing
space just sufficient for the thumb and the forefinger
to hold the tape might prevent the observers from
exerting too much force and tightening the tape and
at the same time provide sufficient pull so that the
tape snugly fits the arm.
Currently available tapes and
currently used techniques of measurement
of mid-arm circumference
The classical method of obtaining circumferential
measurements using a non-stretch tape is shown in
Fig. 1. The markings of the tape face away from the
skin of the subject and towards the observer. The tape
is crossed diagonally to bring the point of origin to
the same level as the final marking. A tape usually is
marked up to 1 mm, and therefore the readings are
read-off in millimetres.
In most of the tapes the markings begin at one end
and there is no space to hold the tape. Some nutri
tionists hold the tape at zero end and also use the zero
marking as the beginning to measure circumference.
In this case inevitably a portion of the finger gets
included in the measurement. This can result in
observer errors amounting to 2-3 mm. Others catch
the zero end between the thumb and the forefinger
and cross over the tape (as shown in Fig. 1). Taking a
measurement from a point 4-5 cm away from the zero
end poses no problem to a trained nutritionist; but
30
© Oxford University Press 1986
Fig. 1. Measurements of mid-upper arm circumfer
ence. (Source: Assessment of nutritional status of the
community, by Dr. Jellifie, D. B. WHO Monograph
No. 53, Geneva, 1966, p. 77.)
Journal of Tropical Pediatrics
Vol. 32
February 1986
C. R. RAMACHANDRAN
Yet another approach to prevent excessive tighten
ing of the tape round the arm is to increase the width
of the tape. Most of the currently used tapes are 1.01.5 cm in width. Tapes which are 2-3 cm in width have
been designed. The wider tapes certainly eliminate the
tourniquet effect. However, such an innovation poses
a problem if classical cross-over (Fig. 1) method of
measuring the circumference is used. In the cross-over
technique, the measurement made is not horizontal
but diagonal. Errors due to diagonal measurement
with tapes of varying width over a range of circumfer
ential measurements are shown in Table I and Figs. 2,
3.
It is obvious that the errors become significant
when the circumferences measured are small and/or
when the tape is wide.
Attempts have been made to design tapes with a slit
near the zero mark so that the tape passes through
this slit after encircling the part. These tapes have also
been provided with a space before zero so that they
could be readily held between the finger and the
thumb. Such tapes have been successfully used in
measuring mid-arm circumference of the neonates
(Belsey: personal communication).
However, two more problems will remain
unsolved. The fibreglass tapes marked in millimetres
are quite useful when the examination is conducted in
bright light by young adult nutritionists. The same,
however, may not be easy if an older individual (e.g.
the traditional birth attendant who is usually in her
forties) examines a neonate inside a house where
lighting is poor. It would be a great help under these
circumstances, if widely spaced markings are pro
vided on the tape. Providing a centimetre tape with a
vernier attachment so that the broad divisions can be
read-off easily by all observers even in indifferent
light, would go a long way in ensuring precision under
adverse conditions.
In all the designs of the tape currently in use, the
readings are taken over a curvature. Reproducibility
in measurement would increase if provisions are made
so that measurements are taken on a straight plane
along the long axis of the tape.
Table 1
The degree oferror in measuring the arm circumference with tapes ofdifferent widths
B
Tape width—10 mm Tape width—12.5 mm Tape width—15 mm
Reading
on the
tape
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
110
120
130
140
150
160
170
180
190
200
Over
reading
reading
True
■ True
reading (mm) (%) reading (mm) (%)
17.3
28.3
33.5
38.7
43.9
49.0
54.1
59.2
64.2
69.3
74.3
79.4
84.4
89.4
94.5
99.5
2.7
7 1
1.7
L5
1.3
1.1
1.0
0.9
0.8
0.8
0.7
0.7
0.6
0.6
0.6
0.5
0.5
15.5
9.1
6.1
4.4
2.5
2.1
1.7
14
L2
1.0
0.9
0.8
0.7
0.6
0.6
0.5
Journal of Tropical Pediatrics
15.6
21.6
27.3
32.7
38.0
43.2
48.4
53.6
58.7
63.8
68.9
73.9
79.0
84.1
89.1
94.2
99.2
109.3
119.3
129.4
Vol. 32
44
33
2.7
2.3
2.0
1.8
1.6
L4
1.3
L2
1 1
1.1
1.0
0.9
0.9
0.8
0.8
0.7
0.7
0.6
28.1
15.5
10.0
7.1
5.3
4.1
3’3
2.7
2.2
1.9
L6
1.4
1’2
1 1
1.0
0.9
0.8
0.6
0.5
0.5
reading
True
reading (mm) (%)
20.0
26.0
31.6
37.1
42.4
47.7
52.9
58.1
63.2
68.4
73.5
78.6
83.7
88.7
93.8
98.9
109.0
119.1
129.1
139.2
149.2
159.3
February 1986
5.0 25.0
4.0 15.5
3.4 10.7
2.9
7.9
6.1
2.6
23
4.8
2.1
3.9
3’3
1.9
1.8
2.8
1.6
2.4
2.1
L5
1.4
1.8
1.6
1.3
1.3
1.2
1.3
1 1
1.1
1'0
03
0.8
0.9
0.9 0.7
0.8
0.6
0.5
0.8
0.7
0.4
D
Tape width—17 mm
E
Tape width—20 mm
Over
reading
reading
True
reading (mm) (%)
reading (mm) (%)
24.7
30.6
36.2
41.7
47.0
52.3
57.5
62.7
67.9
73.1
78.2
83.3
88.4
93.5
98.5
108.7
118.8
128.9
139.0
149.0
159.1
169.2
179.2
5.3 21.4
14.4
10.5
8.0
6.3
5J
3.8
3.3
3.0
2.7
2.5
2.3
2.1
1.9
1.8
1.7
1 .6
L5
1.5
1.3
1.2
1.1
1.0
1.0
0.9
0.8
0.8
3.6
3.1
2.7
2.3
2.1
1.8
1.6
1.2
1.0
0.9
0.7
0.6
0.6
0.5
0.5
28.7
34.6
40.3
45.8
51.2
56.6
61.8
67.1
72.3
77.5
82.6
87.7
92.9
98.0
108.2
118.3
128.4
138.6
148.7
158.7
168.8
178.9
188.9
199.0
6.3 21.9
15.5
11.6
9.1
7.3
6.1
5J
4.3
3.8
3.3
2.9
2.3 2.6
2.1
2.3
2.0 2.1
1.8
1.7
4.2
3.8
3.4
33
2.9
2.7
2.5
1.2
r.o
1.3
1.2
1 1
1.1
1'0
0.9
0.8
0.7
0.6
0.6
0.5
C. R. RAMACHANDRAN
vides just sufficient space for a finger and a thumb to
hold the vernier and the tape. Therefore, it is imposs
ible to exert too strong a pull and cause the tourniquet
effect.
Method of use
The tape is wound round the part to be measured.
The vernier scale is held in hand and the tape is
inserted through the slit into the triangular space. The
slit end of the vernier is held between the left fore
finger and the thumb. The tape with the vernier is held
between the right forefinger and the thumb. The two
ends are gently pulled so that the tape tightens firmly
on the surface of the skin without causing crimping or
wrinkling of the skin. The centimetre marking on the
tape which has crossed the zero mark in the vernier
indicate the circumference in centimetres. Next step is
to find out which of the vernier divisions coincide
with any of the centimetre markings on the tape.
Whichever vernier division coincides, so many milli
metres are to be added. For example, if the zero of the
vernier lies after the 10 cm mark on the tape and 7th
division of the vernier coincides with centimetre line
Fig. 2.
Errors in millimetres for varying lengths of
measurements (for different tape sizes).
Design of the modified tape
The newly designed tape incorporates design
features to overcome all the above enumerated prob
lems. The tape consists of two parts, the main tape
and the vernier.
The tape is made of any flexible non-stretch mater
ial including thick paper, plasticized paper or fibre
glass. It is 1.5 cm wide and half a metre in length. The
zero mark of the tape begins about 3 cm from the end
and markings up to centimetre are made on the tape.
A somewhat thicker material such as thin board
material used 'for visiting cards, plasticized paper or
fibreglass, measuring 12 cm x 3 cm is used for con
struction of the vernier scale. The vernier scale is
constructed in the middle 9 cm by dividing it into 10
equal parts (the scale marked with vernier division is
shown in Fig. 4).
The method of attaching the tape to the vernier is
shown in Fig. 4. The zero end of the vernier has a slit
(Fig. 4), through which the tape is passed after being
wound round the part to be measured. This procedure
ensures that errors due to diagonal measurement are
avoided. The space on cither end of the vernier pro
Fig. 3.
Errors in per cent for varying lengths of
measurements (for different tape sizes).
Journal of Tropical Pediatrics
Vol. 32
February 1986
C. R. RAMACHANDRAN
BASE = WDTH CF TAPE
VERNIER SCALE
? ?
f
?
?
on the tape, then the measurement made is 10.7 cm
(Figs. 5-7).
? S...U
ROHC DESIGN-84
Z
3
4
5 6
7
8
Discussion
9 ~0
CUTOUT THE OSRK TRIANGULAR PORTION
(ID
finished tape
Fig. 4.
Design of the vernier tape.
Fig. 5.
Journal of Tropical Pediatrics
The requirements for a tape to obtain accurate
measurement of body circumference are:
(i) it should be convenient to hold the tape so that
the right amount of pull can be exerted;
(ii) the axis of pull should be along the axis of the
tape; measurement should be taken when tape
surfaces lie parallel on the horizontal plane;
(iii) the markings must be widely spaced to facilitate
easy reading and at the same time precision up to
1 mm should be ensured.
All these requirements have been met in the tape
design presented. The two ends of the vernier strip
provide the means to hold the tape ends so that the
right amount of pull can be exerted and at the same
time undue tightening would be avoided. If necessary
a strain gauge device could be attached to the tape to
indicate the correct amount of tension. The design of
the tape permits the tape and vernier to lie in the same
horizontal plane. This further enhances the accuracy
of reading because measurement over a curvature is
avoided. The slit design of the vernier scale ensures
that the tape is placed such that the long axis of the
two ends coincide. Since measurements are taken
along the long axis of the tape, errors due to diagonal
measurement especially in wider tapes are eliminated.
The widely spaced markings on the tape and vernier
allow easy reading and yet provide the same precision
of measurement as tapes marked in millimetres. All
Measurement of mid-upper arm circumference using the vernier
tape.
Vol. 32
February 1986
33
C. R RAMACHANDRAN
Fig. 6.
Measurement of mid-upper arm circumference using the vernier
tape.
Fig. 7.
Measurement of mid-upper arm circumference using the vernier
tape.
these steps ensure the accuracy and reproducibility of
the measurements even when taken by non-nutritionists.
It is easy to learn how to use the vernier tape. A
couple of demonstrations are sufficient to acquaint
the person with its use. Practice over 2-3 days on
about 50 subjects is all the training needed by any
individual to produce reliable, reproducible measure
ments.
The tape can readily be mass-produced at very low
cost. It is possible to make tapes of varying lengths
(20 cm or less for measuring mid-arm circumference
of neonates, half a metre for measurement of mid-arm
circumference, chest circumference and head circum
ference in children and one metre or longer for meas
urement of abdominal girths in pregnant women).
Disposable varieties can be made by printing the tape
on thick paper. Such tapes can be supplied to tradi
Journal of Tropical Pediatrics
Vol. 32
February 1986
C. R. RAMACHANDRAN
tional birth attendants as a part of the delivery kit. A
more durable variety could be printed on a plasticized
paper or fibreglass and given to workers involved in
large scale community based nutritional surveillance
programmes.
Summary
Factors responsible for observer errors in the cur
rently available tapes and currently used techniques
of measurement of body circumference are discussed.
Design of a modified tape with a vernier attachment
which eliminates observer errors and enhances repro
ducibility even in non-nulritionists’ hands is
presented.
References
U. Jelliffe DB. The assessment of nutritional status of the
community. WHO monograph series No. 53, Geneva,
1966. pp. 77-8.
2. Shakir A, Morley D. Measuring malnutrition. Lancet
1974; 1: 758-9.
Journal of Tropical Pediatrics
Vol. 32
February 1986
3. Burgess HJL, Burgess AP. Modified standard for mid
upper arm circumference in young children. J Trop
Paediat 1969; 15: 189-92.
4.
Persand TVA, Roopnarinesingh SS, Morriss D. A note
on the head circumference of Jamaican babies. J Trop
Paediat 1971; 17: 113-14.
5.
Robinow M, Jelliffe DB. The use of arm circumference in
a field survey in early childhood malnutrition in Bresoga,
Uganda. J Trop Paediat 1969; 15:217-21.
6.
Vaquera MV, Townsend JW, Arroyo JJ, Lechtig A.
Relationship between arm circumference at birth and
early mortality. J Trop Paediat 1983; 29: 167-74.
7.
Velzebeer MI, Selwyn BJ, Sargent F, Pollitt E, Delgado
H. Evaluation of arm circumference as a public health
index of protein energy malnutrition in early childhood.
J Trop Paediat 1983; 29: 135-44.
8.
Velzebeer MI, Selwyn BJ, Sargent F, Pollitt E, Delgado
H. Use of arm circumference in simplified screening for
acute malnutrition by minimally trained health workers.
J Trop Paediat 1983; 29: 159-66.
9.
Gueri M, Jutsum P, Knight P, Hinds V. The arm circum
ference at birth and its relation to other anthropometric
parameters. Archives Latinoamericanos de Nutrition
1977; 27:403-10.
ffUT' <4-
------------------------- / Mismanagement\
Milk products seem the most innocent items
on the international marketing scene. Yet as one giant
food multinational has discovered, making money from
milk substitutes has its headaches. As the World Health
Organisation meets in Geneva to attempt tough new
regulation of the $6 billion world trade in milk products,
James Bellini unravels the tangled story of
intrigue and accusation.
4'
he row has all the ingredients of
a classic political thriller. A vast
multinational with annual turn
over of $11 billion in food, pharma
ceuticals and cosmetics; most of its
brands are household names through
out the world. Accusations of secret
payments and kickbacks to research
institutions and doctors’ associat
ions. A leading international busin
ess publication allegedly used as a
weapon to discredit unwelcome pres
sure groups and beat a boycott. Con
gressional hearings, leaked confid
ential documents. Not to mention
claims of death and suffering on
genocidal scale in dozens of Third
World countries. And at the centre of
the growing storm - a man-made
baby food sold worldwide as part of
the attack on malnutrition and pover
ty!
The company is Nestle. And right
now its corporate policymakers, led
by Managing Director Arthur Furer,
must be cursing the day, 114 years
ago, that their predecessors made
the fateful decision to diversify into
new types of food products for the
baby market. I n the history of market
ing no product has scored more failu»e grades than their harmlesssounding 'infant formula’. No corpor
ate venture could be launched with
such apparently virtuous intentions,
yet in time provoke such vehement
worldwide opposition, as the tinned
powder that lies behind Nestl6gate,
as the episode has been dubbed.
This month, at a high level meet
ing of the World Health Organisation
in Geneva - ironically just a short train
ride from the multinational's Vevey
headquarters - the row is set to reach
crunch point. A draft voluntary code
aimed at regulating the promotion of
baby foods in the less-developed
world is to be debated and, if approv
ed, given the formal backing of gov
ernments. The code would change
the rules of a marketing game that
has brought the major baby food
companies, Nestle above all, massive
profits and the vociferous criticism of
church bodies, medical groups and
community workers.
T
A growing market
Milk is big business around the
world; it grows with the third world
population explosion that in 1980
added 124 million new mouths to the
milk-consuming universe (only seven
million in Europe). Many third world
governments, strapped by low-pro
ductivity agriculture, have grasped
eagerly at milk-substitutes to supple
ment poor diets for their rapidly ex-
panding new-born citizenry. Internat
ional agencies have spent millions
on educating mothers to meet this
problem of inadequate diet. It is this
fast-growing market for milk products
that the food multinationals sought to
capture. Latest estimates put the third
world sales of infant formula at nearly
$1 billion a year.
The arithmetic of milk demand and
supply suggests a vast potential sale
for the right products. Medical spe
cialists estimate that if the world's en
tire population of new mothers were
in full lactation, total world supply of
breast milk would amount to a colos
sal 30 billion litres of milk a year. At
US supermarket prices this output
would have a retail value in excess of
$15 billion annually. But, due to poor
food production, chiefly in the lessdeveloped economies, low protein
intake has cut this potential supply
by 12 billion litres. The shortfall is
equal to a world market for milk sub
stitutes worth more than $6 billion.
And this gap is likely to stay wide in
the years ahead. The forecasts of the
UN agency, the Food & Agriculture
Organisation, indicate that milk
war economic boom, with its accom
panying worldwide population ex
plosion, brought unparalleled riches
to major exporters of milk substitutes.
Nestle. Abbott. Bristol-myers and
Wyeth became surrogate mothers to
literally millions of infants through
Africa. Asia and South America.
Nestle alone was to build a sales
turnover worth $500 million in this
one sector, adding handsomely to
their yearly profits of $700 million
before tax. It is this commercial
achievement, and the consequences
of Nestle's worldwide marketing
strategies, that lie at the centre of
Nestlegate.
Soft sell marketing
During the 1970s, health groups
and consumer watchdogs gathered
mounting evidence suggesting that
the growing use of infant formula in
the third world countries was reaping
a harvest of dangerous, even fatal,
malnutrition and disease - the exact
opposite of the supposed objective
of Nestle's marketing offensive. The
THE DRAFT CODE: A SUMMARY
• Applies to marketing of breastmilk substitutes, other milk products, foods, beverages,
feeding bottles.
• No advertising or other promotion to general public.
• No provision of samples of products to pregnant women, mothers or families.
• No point-of-sale advertising, special displays, coupons, premiums, loss-leaders, etc.
* No distribution of gifts or utensils to promote use of milk substitutes.
• Marketing personnel not to seek contact with pregnant women or young mothers.
• Health authorities in Member states to promote the Code; governments to legislate to
apply the Code.
• No use by companies of health care systems to promote sales, nor use of 'mothercraft
nurses', etc.
• Labels to provide improved information and not to discourage breastfeeding; labels to
carry warnings that artificial products are no proper substitute.
■ Draft Code to become effective 1 March 1982.
demand will rise by some two per
cent a year to 1990. Growth in global
supply is set to rise by a good deal
less; in the mid-1970s, for instance, it
was expanding by just 0.6 per cent
annually. Rising fuel costs, the ex
pense of proper storage and distri
bution facilities, themselves complic
ated by the hygiene requirements of
a highly perishable commodity, con
spire to make milk an unattractive
business prospect, especially in hot
climates where local infrastructure is
traditionally non-existent.
A typical episode in the effort to
raise natural milk output is the recent
attempt by Iranian agencies to boost
natural milk supplies through import
ing 200,000 head of milk cows. The
project turned into a pipe-dream;
gathering such a massive herd from
major farming countries would take
the wrong side of 20 years to accom
plish.
It is hardly surprising that the post
company was spending millions of
dollars in a carefully contrived cam
paign introducing milk substitutes to
poorly educated mothers with low in
comes and no real experience in the
preparation of processed foods.
From Java to the jungles of Africa, the
Nestle message was rammed home.
Remote villages, wonder-struck by
their first battery-powered TV sets.
were regaled with glossy commerc
ials for Nestle products such as Milk
maid sweetened condensed milk
Ran the catchy jingle; "Grow up
speedily, my dear little one Drink
Milkmaid Sweetened Condensed
Milk." The TV campaigns backed up
several years of expensive promot
ion by the milk multinalionals - in
cluding prizes, coupons and en
dorsements by sports heroes.
For Nestle the promotion tactics
captured a growing market But health
authorities were becoming increas
ingly uneasy. The Nestle milk run
said the critics, was causing death
and disease on epidemic scale as
poorly-educated mothers misused
the company's products. As one
source in the Kenyan medical frater
nity puts it; "Virtually every child who
enters Kenyatta State Hospital in Nai
robi with dysentry and vomiting has
been bottle-fed from the early weeks
of infancy." Similar horror stories
emanate from Malaysia. South Ameri
ca and remote corners of the Asian
mainland. "Nestle kills babies" ran
the title of a tract published by a
Swiss-based action group in 1974
The Nestlegate scandal had begun.
The Nestle board reacted swiftly to
the charges. And after a protracted
libel case the company won judg
ment against the action group. But
the fines imposed - 300 francs against
each of the 13 defendants - hardly
suggested massive retribution by the
court Since then the Nestlegate saga
has blown up into a full-scale con
frontation.
Nestle is caught, not with a product
that is unsafe inherently, but with a
marketing outlook which fails to ac
commodate the vastly differing stand!
ards in third world countries. Illiterate^
mothers aredeeply vulnerablewhere
products need added water. In Con
gressional testimony in the United
States. Dr. Oswaldo Ballerin. presid
ent of Nestle Brazil (Nestle head
quarters in Vevey wanted nothing to
do with the US hearings on the infant
formula row) agreed that his com
pany's products should not be used
when local water was impure, nor
where mothers were unable to under
stand the preparation instructions.
A typical illustration comes from
java. A local doctor sets out the facts:
"Condensed milk sells for 150 rupiahs
for a small tin. A labourer in rural
areas earns roughly 40 rupiahs a day.
As a result, people dilute it. 10 parts
water to one part milk, until it becomes
a very thin emulsion." Thus, ignorant
mothers, believing these magic west
ern products to be substitutes for|
breast feeding and dietary supple
ments. supervise the destruction of
their own infants' precarious health.
Other critics point to the apparent
reluctance of Nestle to spend their
immense promotion budgets on
teaching locals to care for themsel
ves. Research in Kenya has shown
that for 60 Kenyan cents a day a
mother could raise her protein intake
sufficiently to feed her children natur
ally. This sum was cheaper than rely
ing on even the least expensive com
mercial substitute. Surveys in the Ivory
Coast indicate that natural feeding
could cost $300 to $400 a year less
than artificial alternatives. But then.
with a $500 million market at stake,
Nestle's reluctance is understandab
le. The company replies that its book
let on breast feeding, published in
1 975, was a major contribution. How
ever. the book contains none of the
diagrams or pictures that are essent
ial in illiterate third world communit
ies.
The boycott battle
The saga entered a new. and po
tentially expensive, phase for Nestle
in June 1977. A pressure group.
INFACT, was formed in the United
States and a boycott of infant formula
companies was announced. The
Minneapolis offices of Nestle were
picketed in what was to grow into a
full scale offensive. Along listof highearning Nestle products was put at
risk Crunch Nescafe. Quik Nestea,
Taster's Choice, as well as associat
ed Libby products.
Nestle dismissed the boycott as
the work of disaffected church and
agitational consumerist groups seek
ing to discredit the multinationals.
Nestle senior management, through
their spokesman Oswaldo Ballarin.
told a US Congressional Subcommit
tee that Nestle investigations had de
termined that the attack on the com
pany "is actually an indirect attack on
the free world's economic system".
The grandiose reaction nevertheless
overlooked the spreading dimens
ions of the story. One instance came
to light in a startling US television pro
gramme screened by CBS. a pro
gramme which suggested a world
wide network of sophisticated pay°f The CBS team had found details of
a commission system operating in
the Dominican Republic through col
laboration between the Big Four in
infant formula. Nestle. Abbott. BristolMyers and Wyeth. Under the scheme,
a percentage of all local sales of
pharmaceutical goods was refunded
to the local doctors' association for
their own use. The total involved tn
one year amounted to some S80.000.
If operated as normal practice else
where m the third world, the commis
sions' involved would be on a colos
sal scale.
Thus, the anti-Nestle lobby gained
strength by the month from a growing
number of sources. By 1978 even of
ficials at the World Health Organis
ation had become involved. An un
official WHO working group called
for a ban on "the advertising of food
for nursing infants" and strict limits
on public advertising of milk substit
utes as well as curtailment of free
samples and sales promotion mater
ials The more Nestle attempted to re
but criticisms - as with Dr. Ballarin’s
testimony - the more the effort back
fired. The exercise was fast becoming
a self-damaging public relations
campaign largely paid for by Nestle.
Ironically, the victim of the boycott,
the US Nestle company, neither man
ufactured nor sold the infant formula
products complained of And the
counter-lobby formed by the com
panies themselves - the Internation
al Council for Infant Food Industries
(ICIFI) - seemed only to exacerbate
the argument.
While the diplomatic wrangle con
tinued. with WHO and its pressure
group supporters on one side and
ICIFI and the milk multinationals on
the other. NestlS decided on 'a more
subtle counter-attack Internal NestlS
documents now reveal a plan to in
fluence public opinion through chan
neling money into a US think-tank
and to secure thereby favourable
coverage in the business press on
the infant formula issue.
Wheel of fortune
The think-tank involved is the
Ethics and Public Policy Center, a
Washington-based tax-exempt insti
tution set up to examine business
issues. The Nestle senior manage
ment worked to generatea pro-Nestle
reaction to the boycott brigade, there
by salvaging some of the tatters of
Protest button : fracas over formula
Nestle's near-ruined image.
At a discreet lunch in an equally
discreet Washington restaurant.
Ernest Lefever, the founder and
president of EPPC, proposed to
Herman Nickel, a Fortune editor
that he be commissioned to write a
study for EPPC on the infant formula
confrontation. The fee would be
$5000. The fee was to be paid in
March 1980, the date for submission
of the manuscript. In March 1980 the
Nestld company gave the Center a
cheque for $5000; both Lefever and
the Nestl6 management insist the
timing of the payment was sheer
coincidence.
In late Spring of 1980, an article
appeared in Fortune that attacked re
ligious leaders associated with the
Nestle boycott. In a key phrase, these
activists were condemned as "Marx
ists marching under the banner of
Christ". Nickel maintains that the
phrase was not his; that it was insert
ed by Fortune editor Richard Arm
strong. But the specific authorship of
the article, and the exact nature of the
fees paid to Nickel, are of little rele
vance alongside the broader issue. A
major business publication had be
come directly involved in a serious
corporate confrontation and some of
its key journalists were penning arti
cles which were far from critical of a
one-sided corporate campaign. Cer
tainly, the Nestle management were
triumphant when the article appeared.
International Vicepresident Ernest
Saunders was to spend much time in
the United States in subsequent
months planning best use of the
Fortune item for the Nestle anti
boycott campaign.
According to a leaked Nestle
memorandum, “there must be max
imum exploitation of the opportunit
ies presented by the Fortune article
and the Ethics and Public Policy
Center's willingness to undertake ad
ditional activity. Mr. Ward (Thomas
Ward. Nestle's Washington lawyer)
informs us that there are ways in
which this matter can be handled..."
In 1980 Nestle gave EPPC $25,000.
It was the largest single donation
from a list of 26 corporate benefact
ors. Though the evidence is incon
clusive, there appears to be a close
connection between large Nestle
contributions and the further use of
the Fortune article to back the anti
boycott campaign. Shortly after re
ceiving $25,000 from Nestle, EPPC
rented a mailing list of 'community
leaders'. The Fortune article, reprinted
and - somewhat appropriately - re
titled by EPPC as ‘Crusade Against
the Corporation: Churches and the
Nestle Boycott', was then distributed
to several thousand opinion-makers.
Fortune charged only a 'token fee' of
$150 tor the reprinting costs. Pre
vious reprint arrangements had been
charged at 10 cents a copy, or at least
double the EPPC deal. The agree
ment represented a disguised donat
ion by Fortune to EPPC worth sever
al thousand dollars Bristol-Myers.
meanwhile, distributed thousands of
reprints to their shareholders and
author Herman Nickel received an
undisclosed royalty.
The wheeler-dealing behind the
Fortune episode high-lighted the
plotting behind thediplomatic facade
of the Nestle public face. Senior edit
ors at Fortune protest their innocence
of conspiring to bend the hearts
and minds of leading opinion-makers
in the direction of the Nestle cause.
But they made little effort to prevent
the wheels of the Nestle PR machine
from rolling onwards, carrying bund
les of Fortune copy onto the battle
field. Nevertheless, thegambit seems
once again doomed to boomerang
back onto the Vevey headquarters.
You know WHO
The latest stage of the Nestlegate
drama, the Geneva conference of
WHO should be the last. Technically.
an endorsement of the code on pro
motion of baby foods should carry
great weight with governments. But
the evidence suggests that yet more
wheeler-dealing is undermining the
painstaking work of WHO officials
and blowing a large hole in propos
ed rules Dr. K.W. Redings from
Samoa, one of the members of the
policy-making executive board, has
already voiced his fears: "the code
has so many loopholes that an un
scrupulous manufacturer could drive
a herd of milk cows through it".
Certainly, the apparently tough re
quirements of the code disguise four
major concessions to the milk multi
nationals. They can still distribute 'in
formation' about their products. With
out proper supervision such a rule
can easily be abused. Secondly, the
code is merely a recommendation. In
this sense, it comes down to the en
thusiasm of individual governments
to make it effective. Thirdly, the code
makes no insistence about health
warnings on product labels and.
fourthly, even admits that baby foods
can be beneficial in cases where
breast-feeding is impossible for
medical reasons.
Thus, the campaigners who saw
WHO as their champion now see it as
a potentially toothless watchdog that
will let the poacher escape once
again. All along, Nestle have encour
aged WHO to act as arbiter. Said
Nestle chief Arthur Furer of the Oc
tober 1979 gathering of WHO: “Our
policy has been to view that event as
the proper forum for discussion of all
questions related to these problems."
But, say the cynics, Nestle have mere
ly realised that in the WHO they have
found a body that will take all the flak
on their behalf, and leave them a free
hand to carry on regardless.
Already. Nestle has brought pres
sure to bear on WHO officials - them
selves granted little real power by
member governments. Early this year
the company-backed front organisat
ion ICIFI applied for affiliate status
with WHO. Nestld Vice-President Er
nest Saunders, who has worked so
hard to milk the Fortune article of its
pro-Nestle by-products, wrote to in
dividual members of the WHO exec
utive board warning that Nestle would
not co-operate with the code if the af
filiation request was not dealt with
promptly. And Dr. Stanislas Flache.
one of the six assistant director-gen
erals of WHO until last summer, was
immediately signed up on his retire
ment to become the first full-time
secretary-general for ICIFI - a body
regarded by many as having objectiv
es diametrically opposed to those of
WHO, at least on the infant formula
issue.
And out in the field, in distant corn
ers of the baby food market where
WHO influence is insignificant, the
signs are that the companies are not
keen to stop consumer advertising or 'demarket', as the proponents of
the code term it. Last year, IB FAN (the
International Baby Foods Action Net
work) recorded 682 violations in 50
separate countries. The milk multi
nationals reply that they cannot pos
sibly control every facet of the local
subsidiary operations. A bizarre res
ponse, since by the same token they
cannot guarantee to maintain specif
ic standards of hygiene at that same
local level, even though this is the
crux of the Nestlegate dispute.
Thus, this latest meeting of WHO
with its much-proclaimed regulatory
code at the top of the agenda, could
mark merely another sorry chapter in
corporate responsibility. In the ab
sence of an effective international
body to monitor worldwide marketing
and use of potentially hazardous
products - whether made so by com
pany or consumer is largely irrele
vant - the multinationals must do it by
themselves. And so far there is little
evidence of a common line.
The British pharmaceutical com
pany Glaxo, for instance, is deeply
cautious about selling products to il
literate and untrained parents. "Glaxo
do not encourage under-privileged
populations to use infant milk powd
er", is the response from Glaxo senior
management. Many comparable
companies share the same view
Some, such as Nestld, do not. In
1979, as the Nestlegate saga gather
ed speed, the company went on
record with its blunt reply: “Will
Nestle abandon the third world? We
will not".
The Nestle approach has long
been that the developing countries
offered the only real growth markets.
The Nestle annual report for 1973 put
it in a nutshell: "in the developing
countries our own products continue
to sell well thanks to the growth of
population...". By 1980 the annual
report was pointing to strong growth
in Latin America and Asia. Between
1973 and the end of the decade.
Asia’s contribution alone to Nestld’s
turnover rose from Sw Fr 1.2 billion to
Sw Fr 2.6 billion. More than Sw Fr 7
billion in sales of all Nestle products
now come from the developing mark
ets of Latin America, Africa and Asia
With markets like these, it is hardly
surprising that the men of Vevey fight
to preserve their grip. The growing 1
risk, however, is that market position
is being protected and expanded
with tragic consequences, certainly
in products where hygiene, careful
preparation and sensible use are key
ingredients of the products them
selves. For milk substitutes such as
Similac Lactogen and comparable
baby foods, many of them the results
of Vevey marketing strategy, the risks
are ever-present And Nestle have yet
to silence the critics who say they are
oblivious to those risks
It seems clear that a WHO code
emanating from the May meeting in
Geneva will not calm the fears of
pressure groups around the world
who say the billion dollar infant for
mula industry is killing its customers.
Nor will it guarantee that Nestle will
adopt a new stance of responsibility
towards the products that have
brought the company much angry
criticism.
And ever-increasing profits. ®
Reprinted from Vision. May 1981: by the International Baby Food Action Network (IBFAN). Geneva, Minneapolis and Penang.
Printed by Lithosphere Printing Co-operative (TU). 203-205 PentonviHe Road. London N1. UK.
*
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32:33
poT--^-.
How do you
like your
...milk?
BST is the first hormone of the new biotechnological genera
tion. It is a test product for the pharmaceutical industry and if its
use is authorized in the Community, it will lead to a whole series
of new hormones for pigs, poultry and fish. The Community has
not yet taken a decision on whether it should be authorized or
banned. In the last analysis it is consumers who have to answer
the question:
Do you like milk ...
With or without genetically engineered hormones?
Bovine growth hormone, BST (bovine somatotropin) is a protein
hormone that all healthy cattle produce in sufficient quantities. In
the young animals it regulates muscle formation and growth,
whereas in adult cows it controls milk production.
What is genetically
engineered bovine
growth hormone?
Genetically engineered bovine growth hormone is not prodMK^
ed by cattle but by genetically manipulated bacteria. The
"
bacteria are altered using biotechnology to produce something
which is foreign to their own organism. BST is not therefore a
"natural hormone". It can be produced in large quantities in
"bioreactors" In many EEC countries BST is already being tested
on calves and cows. In some countries such as the UK, the milk
from these experimental animals is going into the public milk
supply. Plants for the large-scale industrial production of BST are
already producing BST at Sandoz-Kundle in Austria.
Why the need for
this new hormone?
If the new hormone is administered to cows regularly it in
creases their milk yield by 7-14%. The milk yield per cow can
therefore be improved. However, there is no room for an increase
in milk production since milk quotas are already imposed on each
dairy farm in the Community. The pharmaceutical industry is now
offering farmers the prospect of using the new hormone to pro
duce the same quantity of milk with fewer cows, i.e., to get even
more milk out of each individual cow.
What does the BST
hormone mean for
the animals treated?
The hormone only operates reliably if it is injected into the
animals at regular intervals - usually once every two weeks. The
hormone is used especially at the time when the cow's milk yield
has been at its peak, after calving, and is about to drop. The ""
maintains the peak yield for several weeks longer and keeps WRd
at a higher level than normal throughout the rest of the cow's lac
tation period.
BST use can have adverse effects on cow health and welfare
causing:
O tender swellings on the injection site;
O fertility problems and increased embryo loss;
O increase in mastitis (painful udder inflammation);
O increase in the incidence of lameness (due to the feeding of
greater amounts of concentrated cereals);
O failure to gain weight and loss of body condition score, as the
cow is literally "milking off her back".
BST may affect the cow's immunity to desease and could be used
to overstretch worn out cows. All this makes the cost of BST un
acceptable in welfare terms.
What does the BST
hormone mean for
farmers?
The authorization or banning of BST will have a decisive impact
on the conditions for future milk and meat production. Hormones
and performance-enhancing drugs are used primarily in in
dustrial mass production units which no longer have anything in
common with traditionally farming. If the use of BST is authorized
throughout the EEC, it will be used immediately in large intensive
farms. This will bring down the price of milk, thus forcing small
farmers either to do the same thing or to go out of business. BST
treatment produces the desired results in terms of higher yields in
only some 60% of cows. Every cow reacts differently and re
quires the right amount of fodder if it is to maintain a very high
yield. Computer management and continuous veterinary
monitoring is thus the only way of securing the desired gain and
keeping the increased risk under control. BST will mean that
farmers too will have to join the high-tech world, an extension of
the trend towards the industrialisation of agriculture.
The US Congress has estimated that if BST were authorized in
the USA, only farms with a herd of more than 50 could survive.
One third of US dairy farmers would have to give up production.
On, a basis of these calculations, not even half the dairy farms in
Europe would have a chance of survival. One independent
report estimates that if BST were licensed in the UK, by 1994-95
there would be 10% more dairy farmers going out of production
than if it were not licensed.
What does the use of
BST mean in terms of
milk quality?
Only healthy animals can be expected to produce healthy
food. If cows are under constant pressure to produce higher
yields, this will inevitably affect milk quality. Greater susceptibility
to disease will result in increased use of drugs. It is also feared
that BST milk will have a lower protein content and a higher fat •
content. However, milk consists not only of carbohydrates, fat
and protein. Important nutritional elements such as orotic
acid are not present in such high quantities where milk yields
are higher. On the other hand hormone milk contains a higher
percentage of dead cells and white blood corpuscles.
Does the hormone
have side effects
on human health?
The producers maintain that there should be no side effects
since BST residues cannot be detected in milk. However, their
research work has concentrated on improved yields rather than
on the analysis of residues. The growth hormone is apparently
tolerated by the human organism. It is, however, unclear whether
hormones fragments will have side effects on the human body. If
cows injected with BST require more concentrates, it must also be
assumed that there will be increased pesticide residues and
fungal toxins in the milk which it is known can cause cancer.
What does the use of
BST mean for
the dairy industry?
Dairies will be able to buy milk more cheaply. On the other
hand, existing processing difficulties will be compounded. Milk
from high yield cows with a high consumption of concentrates,
kept in intensive large-scale units with increased drug inputs has
already considerably reduced the keeping qualities of milk and its
suitability for cheese making. The average quality of milk will fall
if more and more cows are producing lower quality milk and
farmers with less intensive production are put out of business.
Greater consumer concern for natural and properly produced
foodstuffs will inevitably create marketing problems for the dairy
industry if it processes and markets milk from BST-treated cows.
Could BST help
to reduce hunger
in the Third World?
Hunger in the Third World is not generally caused by insuffi
cient technical solutions but rather by inequalities in the distribu
tion of resources. Thanks to the green revolution and the export
of agricultural technology from industrialized countries to the
Third World, India is now in a position to export wheat. However,
its population continues to suffer from hunger. The BST growth
hormone is also being tested in India. While it is conceivable that
high yield cows will soon produce more milk in India thanks to
BST, they will consume even more cereals and probably have to
be kept in air-conditioned sheds belonging to the large land
owners. Trials show that BST does not work as efficiently at high
temperatures, so it may be not just a costly but also an ineffective
exercise for dairy farmers in India and other developing coun
tries. A growth promotant for cattle will not solve the food pro
blems of the Third World but will incease inequalities and
dependence.
Would it not be
possible to ban
the production and
use of BST?
In the Community a whole series of synthetic hormones have
already been banned following the 1980 veal hormone scandal.
The genetically engineered cattle growth hormone does not come
within the scope of this ban. Under Community law it is treated
as a high-grade veterinary medicinal product and can at present
be tested under the relevant directives.
In September 1988 the European Parliament called for an inter
national ban on the use of growth hormones in livestock farming
- including BST. The producers contend that a ban would in
crease the risk of a black market and the illegal production and
distribution of hormones.
Has the existing
hormone ban
proved effective
to any extent?
The Community ban on certain synthetic hormones has not in
fact managed to prevent infringements occurring in a numbec_of
Community countries. This is primarily due to the fact that the
ban applies only to the use of hormones and not to their produc
tion and the use of hormones can be detected only at a later
stage in meat. In addition, the use of drugs and fattening agents
is the rule rather than the exception in large scale livestock farm
ing. As long as industrialized livestock farming is widely encouraged in the Community and is not cut back to an ecologically^
acceptable scale, it will be virtually impossible to enforce a strict
ban on hormones.
Could a ban on BST
be properly en
forced?
The production of BST requires highly complex genetic
engineering plants. Only four multi-national firms currently have
the necessary Technological know-how to manufacture this pro
duct. They are Monsanto, Eli Elly, Cyanamid and Upjohn. Unlike
synthetic hormones, which are simple to produce even illegally, a
ban on BST could be enforced easily at the production stage. If
representatives of these firms nonetheless maintain that it would
be impossible to enforce a ban on BST, this can only mean that in
the event of a ban they would produce BST illegally.
To dote, approximately half a billion dollars has been invested
in the development of BST. This means that the producing firms
and politicians are both under pressure to market the new
generation of hormones. The producers are spending a great
deal on advertising to present the new growth hormone as
harmless, useful and natural. For them a ban on BST would mean
not only a considerable economic loss but might also threaten
other genetically engineered products which are controversial
owing to their unquantifiable risks to humans and the environ
ment. The industrial application of biotechnology and genetic
engineering is in its infancy. There is still time to reverse decisions
and develop alternatives.
[What can I do?
At present only a small number of people are able to imagine
how genetically engineered products such as the BST cattle
growth hormone will actually affect their lives in practical terms.
Please discuss this issue with other people. Throughout Europe
there are consumer, animal welfare and farmers organisations
which have taken a stand on this issue and are running informa
tion campaigns about cattle growth hormone. Only if pressure is
brought to bear on national governments and the EEC Commis
sion will it be possible to get through a Community-wide ban. Let
your Members of Parliament and your milk suppliers know that
you are not prepared to accept the legalisation of BST. A con
sumer boycott of BST milk would have far-reaching consequences
that no politician can afford to ignore. Should BST be licensed, in
sist that milk from treated cows is labelled as such.
For further information please contact:
Compassion in World Farming
20 Levant Street
St. Petersfield
Hampshire, GU32 3EW
Tel.: (0730) 64208/68863
Reproductive and Genetic
Engineering
European Editor Renate Klein
P.O. Box 583
London NW3 IRQ
London Food Commission
88 Old Street
London EC1V 9AR
Tel.: 01-253-9513
The Green Party Ireland
5a Upper Fownes Street
Dublin 2, Ireland
Tel.: 01-771436
The UK Genetics Forum
17 Luxor Street
London SE5-9QN
Tel.: 01-73305 74
Gen-ethic Network
Potsdamer Str. 96
D-1000 Berlin 30, FRG
Tel.: 49-30-2 61 85 00
An information of:
Rainbow Group GRAEL
European Parliament
Hannes Lorenzen ARD 319
97-113 rue Belliard
B-1040 Brussels, Belgium
Tel.: 32/2/234 3053
HepyiAtt/t i*' IwUa- lv-
cz
inp
testMUj* foiakMTion FeA
T&UtMOUOft'f.t-MhT. HEStaWi tOUGf
(OS’ PAJPWH MAb
beitP-Ar W -I4&OOI.
typei.Hing: kippsorz Bonn/Typo-Concept Koln "fd- ■ 0’ 2-33 T 4
graphic & lay out: P. Laos, Bergitr. 62, D-5354 Metternich (FRG)
genetically
engineered
hormones?
Hormons are vital to life. They regulate many physical functions
in humans and animals. However, as an aid to meat production
they have fallen into disrepute and since 1988 their use has been
banned in the European Community, although, as recent in
cidents show, their illegal use continues. The pharmaceutical in
dustry is now producing a new generation of hormones which it
describes as "natural". These new hormones are produced by
genetic engineering which means that they are the result of
technical, microbiological manipulation. Genes, which contain
certain inherited data, are isolated from the cells of cattle, for ex
ample, and implanted into bacteria which would not otherwise
have such characteristics. This enables bacteria to produce
unlimited quantities of bovine growth hormone - also called BST.
How do you
like your
milk?
Id/fa/you always wanted
to ask about gene
technology but were afraid
to find out the answer
with or
without... >>
... genetically
engineered
hormones?
<J
b
TABLE - 1
B-COMPLEX
Brand Name
Complex B
Glaxo
TABLETS
Elemental Vit.Bl Vit B2 Vit B6 Vit B12 Vit FA
iron in
mg
mg.
mg.
mg.
mg.
mcg.
-
3
1
0.5
Nicacid
mg.
Cap.
panto.
mg.
30
-
5
Vit.C
mg.
Price in paise
for equivalent
doee Ibased on
price in june 81.
1
-
-1 tablet cf 4 paise.
14.6 ( IT = 44 paise)
Libex
-
3.3
3.3
1
2.66
.33
30
-
50
Becozyme -C
-
3
3
2
2
-
10
5
40
9.3 ( IT = 46.5 paise)
Cobadex Forte
-
5
2.5
1
1
. 5
7
1
20
4.45 ( 1 T=44.5 paise)
Beplex
-
10
2.5
0.5
-
-
25
3
-
1 T = 4.25
B-COMPLEX INJECTIONS
Complex B glaxo
-
5
.5
1.5
5-25
2.5
-
0.5 ml t 17
Bej ectal
-
5
1
2.5
-
2.5
-
0.5 ml '. 34
0.75
TABLE - 2
Brand name
Vit.Bl
;Vit.B2 !
mg.
1 mg.
!
MULTIVITAMIN
TABLETS
Vit.B6JVit.B12 ! Vit . i Nic. JCa-
; vit a
mg. !
mcg
FA
, mg.
| Vit.
' Vit. ! Mine-
Iron
J
J acid [ Panto .' I.U.
; d iu
> mg.
' nig.
■
i
,rals
c
mg.
' solt
mg
;
•
J
I
Price in paise
for equivalent
dose, (based on
prices in June
1981).
Vimgran
3
3
1
2
0.1
20
5
5000
500
50
-
-
13.5 = 1 Tablet
Vitaminets
Forte
10
2
3
1
-
10
10
4000
400
50
-
-
18
=1 Tablet
Multivitaplex
Forte
2.5
2.5
,5
1.25
.25
5000
3.7
38
-
-
10
(59.5 = IT)
25
MULTI VITAMIN SYRUP
Multivita-pl ex
3.5
2.7
1
-
20
5000
1000
50
Becadex
1.5
1.2
-
2.5
-
10
3000
500
40
-
-
5 ml = 21.45
Visyneral
1.5
0.6
1
2
-
10
3000
1000
50
-
-
5 ml = 32.75
1000
50
5000
1000
5000
500
50
______
30
5000
400
25
2
5 ml = 38.65
1MULTI VITAMIN :DROPS
ABCDEC
Vitamin M
drops
__________________
Alvite
Vi-Syneral
1
0.4
5
1
1.5
1.2
.5
10
2
1
5
0.5
1.5
-
-
2
10
__________________
20
-
10
-
5000
0.6 ml. = 14.2
Mn K 17.27
Zn___
0.6 ml = 17.08
-
-
55
-
-
48
TABLE NO.3
IRON WITH MULTIVITAMIN TABLETS
Brand Name
Vit
Bl
mg.
Vit
B2
mg.
Vit
B6
mg.
Vit
B12
mcg.
FA
Vit
FolicI C
acid
mg
mg.
Cap
Nic
panto. acid
mg
mg
Elemental
Iron in mg.
Price in paise for equivalent
dose(based on prices in Jane 81
6.3(1 tablet costs 19 paise.)
Iberol
1
1
0.5
4.6
.33
25
1
5
52.5
Exifol
2
2
1
100
5
50
3
10
45
1 T 4 59
Fesovit
2
2
1
-
-
50
-
15
45
1 T = 60.3
Fersolate
+ Complex B
Glaxo
3
1
.5
5
-
—
1
30
60
— — —------- ---- U —
“"IRON ■"WITH " FOLIC ' acid"and "VITB 12
1 T = 7.5 paise.
--------------------------------------------- -------------—
Ferplus
66
5
1
150
66
1 tablet = 34.3
Femitinic
10
1
150
66
1 T = 41.8
Macrafclin
with iron
10
1
-
66
1 T = 6.5
Autrin
9
1. 2
90
70
20.76K1T = 34.6)
(34.6 x 3/5)
Rediplex
10
1
100
68.6
21.3 (IT = 32)
(32x 2/3)
3.5
66
Fersolate
Imforon Fl2
668
3. 2
66.4
154
Uniferon Fl2
66.4
3. 2
66.4
76
(Tables prepared by Nitin Sane, Pune).
1
TABLE
TABLETS
B-COMPLEX
Brand Name
Complex B
Glaxo
Libex
Becozyme -C
Cobadexi Forte
Beplex
Elemental Vit.Bl Vit B2 Vit B6 Vit B12 Vit FA
iron in
mg.
mcg.
mg.
mg
mg.
mg.
-
Bej ectal
-
Cap.
panto.
mg.
Vit..C
mg.,
Price in paise
for equivalent
doee (.based on
price in june 81.
3
1
0.5
5
-
30
1
-
3.3
3.3
1
1.66
.33
30
-
50
14.6 ( IT = 44 paise)
3
3
2
2
-
10
5
40
9.3 ( IT = 46.5 paise)
5
2.5
1
1
. 5
7
1
20
4.45 ( 1 T=44.5 paise)
10
2.5
0.5
-
-
25.
3
-
1 T = 4.25
25
2.5
-
0.5 ml i 17
0.75
2.5
-1 tablet of 4 paise.
INJECTIONS
B-C
Complex B glaxo
Nicacid
mg.
5
.5
1.5
5
5
1
2.5
-■
-
0.5 ml : 34
TABLE - 2
MULTIVITAMIN
! rals
; c
; mg.
-
1 Vit. i Mine-
; d iu
rH cf
; vit.
a
; vit a
O
; fa
TABLETS
B
Vit.B6'Vit.Bl2 ! Vit. ■ Nic. ! Ca-
!
;vit.B2 !
1
Vit.Bl
j H
Brand name
Price in paise
for equivalent
dose, (based on
prices in June
1981).
i mg.
3
1
2
0.1
20
5
5000
500
50
-
13.5 = 1 Tablet
10
2
3
1
-
10
10
4000
400
50
-
18
=1 Tablet
2.5
2.5
.5
1.25
.25
5000
3.7
38
10
(39.5 = IT)
Vimgran
3
Vitaminets
Forte
Multivitaplex
Forte
!
25
'
mg.
W
’ mg.
p
mcg
mg*
° s
mg. |
! acid {Panto .' I.U.
! mg.
MULTI VITAMIN SYRUP
Multivitepl ex
3.5
2.7
1
-
20
-
5000
1000
■50
Becadex
1.5
1.2
-
2.5
-
10
-
3000
500
40
Visyneral
1.5
0.6
—
1
2
—
10
2
3000
1000
50
-
-
5 ml = 38.65
-
5 ml = 21.45
——
5 ml = 32.75
MULTI VITAMIN DROPS
-
5
2
5000
1000
50
-
-
-
10
-
5000
1000
50
Mn K 17.27
Zn
-
-
20
-
5000
500
30
-
-
55
-
10
-
5000
400
25
-
-
48
ABCDEC
1
0.4
1
Vitamin M
drops
1.5
1.2
.5
Alvite
10
2
1
Vi-Syneral
5
0.5
1.5
-
-
-
0.6 ml,. = 14.2
0.6 ml = 17.08
TABLE NO.3
IRON WITH MULTIVITAMIN TABLETS
Brand Name
Vit
Bl
mg.
Vit
B2
mg.
Vit
B6
mg.
Vit
B12
mcg.
Nic
FA
Vit
Cap
Folic C
panto. acid
mg
acid
mg
mg
__ mg.____________________
Elemental
Iron in mg.
Price in paise for equivalent
cose(based on prices in Jane 81
Iberol
1
1
0.5
4.6
.33
25
1
5
52.5
6.3(1 tablet costs 19 paise.)
Exifol
2
2
1
100
5
50
3
10
45
1 T 4 59
Fesovit
2
2
1
-
50
-
15
45
1 T = 60.3
Fersolate
■+ Canpl ex B
Glaxo
3
1
.5
5
1
30
60
1 T = 7.5 paise.
-
IRON-'WITH'FOLIC' ...CID AND VIT B 12
66
5
1
150
66
1 tablet
Femitinic
10
1
150
66
1 T = 41.8
Macrafclin
with iron
10
1
66
1 T = 6.5
Autrin
9
1.2
90
70
2O.76J61T = 34.6)
(34.6 x 3/5)
Rediplex
10
1
100
68.6
21.3 (IT = 32)
(32x 2/3)
3.5
Ferplus
- -
66
Fersolate
Imforon Fl2
668
3,2
66.4
154
Uniferon Fl2
66.4
3.2
66.4
76
(Tables prepared by Nitin Sane, Pune).
34.8
TABLE - 1
B-COMPLEX
Brand Name
TABLETS
Elemental Vit.Bl Vit B2 Vit B6 Vit B12 Vit FA
iron in
mg.
mg.
mgo
mg
mg.
mcg.
Nicacid
mg.
Cap.
panto.
mg.
Vit.C
mg.
Price in paise
for equivalent
dose (.based on
price in june 81.
-1 tablet of 4 paise.
Complex B
Glaxo
3
1
0.5
5
-
30
1
-
Libex
3.3
3.3
1
2.66,
.33
30
-
50
14.6 ( IT = 44 paise)
Becozyme -C
3
3
2
2
-
10
5
40
9.3 ( IT = 46.5 paise)
Cobadex Porte
5
2.5
1
1
. 5
7
1
20
4.45 ( 1 T-44.5 paise)
Beplc:
10
2.5
0.5
-
-
25
3
Complex B glaxo
5
.5
1.5
5
25
2.5
Bej ectal
5'
1
2.5
-
0.75
2.5
’
1 T = 4.25
B-CC"''Pl,EX INJECTIONS
-
-
0.5 ml s 17
0.5 ml ; 34
TABLE - 2
MULTIVITAMIN
'Brand name
Vit.Bl
mg.
jvit.B2 !
1 mg.
!
Vit.B6; Vit.B12 J Vit. iNic. J Camg. ;
mcg
J FA
i mg.
0.1
Vimgran
3
3
1
2
Vitaminets
Forte
10
2
3
1
Multivitaplex
Forte
2.5
2.5
.5
1.25
.25
TABLETS
; vit a
J acid [Panto .' I.U.
J mg.
;
jVit.
1 Vit. !Mine- ; Iron
| D IU
! mg.
;
,,
I rals
c
mg. '
20
5
5000
500
50
10
10
4000
400
50
25
-
5000
3.7
38
' solt
'
-
J
J
i
Price in paise
for equivalent
dose, (based on
prices in June
1981).
13.5 = 1 Tablet
18
=1 Tablet
-
10
(39.5 = IT)
-
5 ml — 38.65
-
5 ml = 32.75
MULTI VIT.IMIN SYRUP
Multivita
plex
3.5
2.7
1
-
20
-
5000
1000
50
Becadex
1.5
1.2
-
2.5
10
-
3000
500
40
Visyneral
1.5.
0.6
1
2
10
2
3000
1000
50
ABCDEC
1
0.4
1
-
Vitamin M
drops
1.5
1.2
•5
Alvite
10
2
Vi-Syneral
5
0.5
5 ml = 21.45
MULTI VITAMIN DROPS
-
5
2
5000
1000
50
-
10
-
5000
1000
50
1
-
20
-
5000
500
30
1.5
-
10
-
5000
400
25
0.6 ml. = 14.2
Mn K 17.27
Zn___________
0.6 ml = 17.08
55
-
48
TABLE NO. 3
IRON WITH MULTIVITAMIN TABLETS
Brand Name
Vit
Bl
mg.
Vit
B2
mg.
Vit
B6
mg.
Vit
B12
mcg.
Cap
Nic
panto. acid
mg
mg
FA
Vit
Folic C
mg
acid
mg.
Elemental
Iron in mg.
Price in paise for equivalent
cose(based on prices in Jane 81
Iberol
1
1
0.5
4.6
.33
25
1
6
52.5
6.3(1 tablet-costs 19 paise.)
Exifol
2
2
1
100
5
50
3
10
45
1 T 4 59
Fesovit
2
2
1
-
50
-
15
45
1 T = 60.3
Fersolate
+ Canpl ex B
Glaxo
3
1
.5
5
1
30
60
-
Il; Cd with POLIC~ ..C'iD"AND~VIT“B'12
1 T = 7.5 paise.
—
'
Ferplus
66
5
1
150
66
1 tablet
Femitinic
10
1
150
66
1 T = 41.8
Macrafolin
with iron
10
1
-
66
1 T = 6.5
Autrin
9
1. 2
90
70
20.76i£>lT = 34.6)
(34.6 x 3/5)
Rediplex
10
1
100
68.6
21.3 (IT = 32)
(32x 2/3)
3.5
66
Fersolate
Imforon Fl2
668
3.. 2
66.4
154
Uniferon Fl2
66.4
3. 2
66.4
76
(Tables prepared by Nitin Sane , Pune).
34.3
JWT- 10 ■
----— A Wowder Gift Off Mature
i
l
The microplant is the richest source of protein, vitamins and minerals.
A Ithough the green revolution has
increased the availability offoodT ^.grains, protein-calorie-malnutri-
tion is prevalent in many parts of the
world. People who are poorly nourished
and undernourished represent approximately one-eighth of the human popula
tion^
_ _____________
i ■ • Accerctng to the 19.3 report of World
i Food Council (WFC), about one billion
i people sutler from chronic undemutrition
I
j
;
I
Sout
malnutrition.
ics to fight the
:a!orie supply by enrtas a direct bearing on the total foodgrains
production.
Two: Ensuring
availability of-pro
tein both in terms of
quality and quantity, j
Well, as far as
the first point is con- |
cemed, we are self- t
sufficienti.e,in the
mal protein or soya protein. '
such pulses in the Indian subcontinent has
decreased from 54 g/day to 44 g/day as
Searching alternatives
per FAO production year book 1983.
Statistical data show that most Indians The'decline may be due to the specprefer rather vegetarian sources ofprotein.
tacular increase in cereal grain production.
But, sadly, the per capita consumption©!
riowever/tHe "pulse production over the
years has more or less stagnated not only
•
iillndia_buUtHhfi.worLd_aia.wr,ole,____
Spirulina gbt-its name due
to its spiral shape. It is the
richest source of protein,
vitamins.and. minerals in
the world, . it also pos
sesses abundant amount of
natural pigments/blue,
green, orange and yellow.
jn S’S^^XZridSa
se2rch for alternative renewable sources
med inci
ina.
gae or cvai:obcc:eric. dominated the
world scenario.
to 3.2 billion years ago. These organisms
bacteria and plants,
but due to dominance
of chlorophyll and
other blue and yellow
pigments, they are
K3 placed
under
< microplant category.
Spirulina got its
name due to its spiral
shape.-.It is the richest
source of protein, vi
tamins and minerals in
.the. world, --It also pos'4-: sessejsabundant
i amount ofnatural pig. ments, blue, green, or. ange and yellow.
^..Dominance, of.
blue-green pigments
cient or surplus
amount of fooddf^rj
grains for our grow
ing'population.' The .second i.e./ the-availability of pro
tein, both in terms
' ‘ ofquality and quari- tity, can be achieved^
either through "ani-J
IT ’Microscbpicytew ofSpirulintr''*..
Health Action o. January '97.
gives its reference as
skin and all tissues.
blue green algae. The
Protects eyes from
algae are nothing but
conjuctival xerosis,
micro and macro
oral and other body
plants which are
parts
■' from
green in colour and
oncological lesions
found abundantly in
and manifestation,
all sorts of water bod
thus averting risks of
ies ranging from.
getting cancer.
pools, puddles and
The National In
ponds to rivers and
stitute of Nutrition,
oceans.
Hyderabad, under
Spirulina is also a
Indian Council of
typical algae form
Medical Research
discovered for the
has already estab
first '■ time from
lished the effective
Mexico and Chad
nutritional and long
lakes. The lakes, al
term toxicological
kaline in nature, posaspects of spirulina.
sess lots ofbicarbonChlorophyll or
Ties, nitrates, sulphates arid phosphates—
the needs of major food, pharmaceutical
g^blood - stmcturallV-Similarjo
a staple diet of spirulina.
and cosmetic industries all over the globe.
hemoglobin - is substantially present
Tribes of Mexico belonging to Aztec
Medically, this microplaAt also'deals a - alon§ w,th lron ■n.bioavailable form,to
and those of Chad were voracious eaters
lot witirsome^hcmTprevcntivetKerapeu--'" curbanaemiajtjs;also the one andonlv__
of this microplant.' They also marketed it
nicTp^iSRH^nlFh^
- vegerablcsourceofcyanocob&Jor..
in the local and national markets as a
bTaffSlri^diabwS^^
staple and healthy food.
’ciffhosi^pancrcaticjiains,'wounds?night-" -J.^ngtheinng pro?SW s yat .-su..ou.,<-: g
They consumed' it mostly during
■Piihiin^j anaeimaj rheumatoTJffthfifisj"
.
drought periods when food grains were - agSihK^iHCmas^lh-ctmipir^aToYof essential fatty acids lute
scarce. The Europeans who’carried out
'the normal yell-being of theihumjn bod<
^ainnia
an ?;0
various expeditions in North America and
—
Z7™ J’almost
ZZZ - ’—ds makes it a ‘potent tool
It is. a rich source Oi B-carotene
. to curb heart
Africa brought this microplant to their
iq
7
ailments. obesitv, arthritis and for proper
18 times more than carrot. jBeing a pj.c.
,
laboratories and were astonished to see --cuHhFm^S^nd a’pfc^'nti^ — ^'on.ngofcellniembran^preotrsors .
■' that its protein content was over 70%. in
dant, it helps in maintaining
of P^aglandm, regulating the safety of
addition, it contained. 18 aminoacids, in___ „____ _—7— ■;-------- --------- i '
all tissues,- especially those hit by
cluding 8 essential ones out of 10 recom
hypercholestcrolic conditions.
mended by WHO, besides numerous vi
Recent studies carried out by scientists
tamins, minerals, lipids, carbohydrates and
ai Bangalore, Ooty
at
uoty and
ano Jaipur show that
uuu .■
natural pigments in abundance.
daily intake of spirulina at 2-5g dose helps
With the further progress in science and
in wound and ulcer healing. It also re
technology, attempts were made all around
duces SGPT and SGOT enzymes levels
the globe to tame this microplant or to
in blood, thus helping in prevention of
grow in artificial ponds.' Result: a new
chronic liver cirrhosis.
dimension to a new technology leading
Presence of some other vitamins like
to green revolution.'
biotin (Vit. H), tocopherol (Vit.E), thia
Scientists, especially in USA, Mexico,'
mine, riboflavin, niacin, folic acid,
Israel and India,;did poineering work in
pyridoxic acid etc in appreciable quanti-ti^'ako' nouri^hes the human body besides
. this field because-this plant was locally-?.
available’ arid easily"adapted itselfto locali
iB^afdfeni^ha^vitamirf-- BlZ^iiejn
. cohditiopslGftiJlIll^riJ'Zfri1-^'
u;:n, _ _____
* ~Thqlate Dr'Civ.'Sesiiadn, Director of
U1.■ ' '■.
. -.isyitamin-E prevents ageing, help’s in •
■ ShriAMMMunigappriChe^iarResearch''-- IiT]^OiQtdllh:[iuS%(]ein^^W::t 5beltcrment;of.skth'’and hair.-’Thusit has;,
'Medical !y, -this. mi crp'plan t
also’ deal s^ajl oh w,i t&om e
c|iem®p^pnfi\&n^d-;
"til I’P1 ....... .
i n areas wancetfhearfai I?
atlCCpainSWOlifldWl.CintU-'
- Centre,-Ma<h-as,^piayed:a :yitai"r61e~and'febeebrnfr'ii' irreplaceable' ingredient In i
intrqduced its mass cultivation technology.’-- :iC6TffJ
i:shampdos',«soaps,'’-i'ace cream's 'and bthef].
■ to IndianpM^oma’m^e^iy
lW®nnW: • cosmbti^in^cdientsjs-^ij
"Th?s^e1)w1^1^'’61dgyis~riowa^il-'v-hg^b4^^wH^y ^^^^^-.T>‘::.^rHvsis^n'd 'experiments carriecfout
able in iri’d
diaiui
Sbu’th’^'Asiatofirifiii.ri
Eakt'ASi'ato fulfill ri.. itnejnUrn.aniBOdyqfe'^^^^^.'t-'Gn'various
i
I ableiriiri
la^’dSbuth
Tcseafch-’lab6ratdnes ;wor'Id-:
.nCr^S^ljaGteW®|3.riUj,»
Health Action • January ’87*
also
wide lias pinpointed
a factspirulina is a
wonder gift ofnature
— a well-balanced
food with lots of
chemo-preventive
and therapeutic ap
plications besides its
use in cosmetics and
it has no side-effects.
Further, more
toxicological and nu'tntional studies with
friendly micro-plant,
nature to mankind.
Sunora Spirulina and
'Multinal are its mar-.
larkct,—
rather
"spirulina iiFlndia, it
‘has -also'been made
available" to "pooF
silkworms to poultry
“people~ofbufcountry~
Eave revealed that
—ShfF^AnpaL
'-spirulina is a good
'"‘^S^-Murugappa'Chettiar
—ReScafch“Centrc in
- shortenstlieSevelop
Women from earthquake-affected area ofLalhur Disk undergoing training in Spirulina cultivation
—the-form~yf one.
ment periods, im
Spirulina alkaline to saline waters,
parts new colour to fishes and to egg yolks
loves desert conditions, enough sunlight
l"~uonai~snpplem'5iftation programmes car;
and increases their working capacities
and moderate to high temperature ranges.
"neiioutbyMCRCby feeding spirulina to
besides increasing their life-spans.
On per acre yield basis, Spirulina con
"5000 pre-schooTcliiIdfeiTfor a year jn.
Spirulina has also been tested and
sumes just l/10th of water consumed by
proved as a best supplementary feed for
soyabeans but gives twenty times more
- —the aegis ofdepannie'nt~ofBiotecnnolo>t.v... ;
shrimps, prawns, fishes, silkworms, poul
protein as it can accumulate upto 70%_.
' Ministry!,f Science and Tcehnojogy,-Gov-- I
try, pigs etc.
emmenfol India, New Delhi. „—
Cosmetics — the threshold area awaits
“Besides this, spirulina liberates tonnes
------ "Similarly, many women in Tamil Nadu I
i a great future from spirulina. It also conand tonnes of pure oxygen into the envi
are pro‘ducing-theulgaeimheir courtyards- |
j tains green, yellow, orange and blue pigronment through its photosynthetic ma
-thrdugh techmcaTTieiyirom~?vlCRc. In
I ment upto 20% level.
chinery by consuming tonnes and tonnes
I
- They are non-carcinogenic and easy to -of carbon-dioxidc.--Thus,-spiru|ina-is not- nhe~slmeTannection, MCRC is presently__ .
’ engaged in giving employment to hun- /
I be incorporated in various facial mask foronly a good food, feed, cosmetic, thera
"drills’ of women in "eariliquake-hit areas^
i mulations. Phycocyanin is marketed as
peutic and chemoprcvcntive ingredient but
.
‘
“of Eatifr"and OSmanabatTclistricts through! j
■ luna-blue in Vietnam and Taiwan for eye
lashes and facial masks. These pigments
spirulina production^
.
" The project SERVE — Spirulina for
not only improve the facial value but also
Employment .Generation and Rehabilita
increase immunity and retards ageing, if
tion of Victims of Earthquake is the first
taken orally.
-y® % •: • .
. of its kind on the globe... It aims at not
With wide applications of spirulina in
only tackling the problems of health and
food, feed, therapeutic, to cosmetic fields .
malnutrition in the area but also to give a
today’s major food, pharmaceutical, and
sustained income to earthquake victims.
cosmetic industries are poised to tap this
It is also sponsored by DBT, MST, Gov
natural gift of nature. ■ -. ,fri. jiV) jnSiernment of India, New Delhi.
Presently only three companies in In- ■
-In the near future, iceaing
feeding the
algae «
at
. . ..intnenearluture,
me aig«
dia.are producing this rare plant,for,,the-:
Indian .and.international.marketi,The an-.
the area will not only improve jhcir.health ,.
: nual. production-is around;250 tt.0nnes_.a3■' • and mental status, but will also come close,
_
jfbiMacddjas^-gn^^w'oni^^
to the dream of our late, Prime Minister,
mendation. that .a healthy
ilthy ;:medium-size ' y
£ Smt.Indira Gandhi, that, Hjq child shoidd,
adult should consume
'
■ T.
undernotm.shed’’..i-;.1Jf ..(JQ ■"
" 7"3^.mlhi0oltl^^<hap^aipatc|y>g.';;
" Tangmg'lromTishcs,
JSpirulinaL
■
^GonsumesSjusite'wi
consumeob^l
' millionhectocsoribil_liqnaCTes.ofdcscrt^:>r
-. land in warm cimat^?^^afdsjgbputg^;
: 16,00p.^tuirejnil^
’• agriculturgll^^oqpl
32 - '
a®
s'^-Murugappa Chettiar Research Centre, •
■" Health/vctipn^ January’?-
CENTRAL THEME
FOOD AND NUTRITION
The Central Theme of each Tibetan
Health covers one of the important activities
of Primary Health Care (PHC). Previous
issues have looked at Maternal and Child
Health, Immunization, Water and Sanitation
and Health Education. Here we will consider
the role of Food and Nutrition in PHC,
particularly as it relates to Tibetan communi
ties in India and Nepal.
Introduction
9
For Tibetans, as for people of many
other cultures, food fills more than the belly.
It plays important roles in spiritual and daily
life that are not directly related to its nutritive
value, yet may influence peoples lives very
significantly. These aspects of food have
important implications when considering
nutrition. After water, food is the most
essential ingredient for human survival. As
our primary source of nutrition the socio
political power of food is enormous, at all
levels—individually, in the family, in the
community, for the country, and globally—
where other determinants such as finance
and political expendiency often lose sight of
its basic function (nutrition), so that despite
adequate global food production, huge
numbers of the worlds population continue
to starve.
From the strict health perspective
obviously the nutritive aspect of food is the
most important in immediate terms. However
the socio-political aspects cannot be ignored
and until they are addressed health care
services will always be faced with nutrition
related problems caused by the inequitable
distribution of food.
Nutrition for Tibetans
How we eat is largely determined by
how our mothers fed us, what food is cultiva
ted and readily available, how it is prepared
and consumed, how it is stored. This is tradi
tional knowledge that we do not question
and eating practices that have evolved over
many years are usually nutritionally sound
and suitable for the conditions in which they
have arisen. It is when the conditions change,
such as with industrial development or
migration that inappropriate continuation of
the old practice may compromise the nutri
tional status and health of the family. The
climate and conditions of the Tibetan plateau
in no way prepared the fleeing exiles of the
late 1950s and early 60s for the conditions
they were to meet in India. The extreme
dryness and cold that they were used to
combined with the relatively low population
density mitigated against the survival of most
of the micro-organisms that commonly cause
infectious disease in warmer, moistcr, more
populous places. Thus traditional Tibetan
food practices did not protect against the rapid
invasion and multiplication of germs capable
of causing infectious diseases. Practices such
as drying of food for later consumption and
the inadequate reheating of food, while suita
ble and economic for Tibetan conditions
have indirectly led to much sickness and even
death when continued under Indian conditions. •
The other thing to change in the new environ
ment was the type of food available. Then too,
the actual composition of the traditional
Tibetan diet, with its high fat and salt content
3
appropriate for the different metabolic
requirements of a cold dry climate was not
appropriate for the new conditions, both in
terms of life-style and availability. For most
Tibetans even the basic staple carbohydrate
was different, wheat or rice instead of barley.
Everything was different, the basic foodstuffs
available, the methods of preparation and
storage, the metabolic requirements of the
people and the unseen army of pathogenic
organisms waiting to invade unprotected
food, causing diseases previously not experi
enced.
Thus the conditions for good nutrition
for Tibetans in prc-1950s Tibet were quite
different from those of Tibetan refugees in
India, (and probably different again from
those of the Tibetans who are now remaining
in Tibet.) information about the stale of
nutrition in Tibet prior to the Chinese
occupation is all anecdotal (i.e. only available
indirectly through personal accounts). Simi
larly, reliable and medically significant
information about the current health status
of the indigenous Tibetans is difficult to
obtain. However eye witness accounts refer
to specific deficiency diseases—blindness and
eye disease from vitamin A deficiency,
anaemia from iron deficiency, goitre from
iodine deficiency, rickets and scurvy—and
generalized protein - energy malnutrition with
stunted growth.
The situation of the Tibetan refugee
population in India and Nepal is not much
better elucidated, with little in the way of
anthropomorphic (growth measurement) stud
ies on the first generation of children to grow
up here. Those who came to India as chil
dren suffered appalling hardship on the
journey which, when compounded by ex
posure to new infectious diseases meant many
of them died. They subsequently grew up
in huge residential schools where the basic
nutrition, especially in the early years was
often insufficient for optimal growth. Other
factors such as the
massive changes
in lifestyle and disruptions to families, could
be expected to have had negative effects on
the growth of these children. The second
generation children appear to be both taller
and heavier than their parents.
What is Nutrition ?
Nutrition is the study of food and the
way our bodies use food. The science of
nutrition has made great advances over the
past few decades but that has not necessarily
helped us in our practical understanding and
implementation of the theory in our daily
eating habits. Preoccupation with the fine
details of calorie counting and what consti
tutes a “balanced” diet tends to ignore the
important realities of food supply, the ability
to buy etc. Briefly, the food we eat can be
described as :BODY BUILDING FOOD (proteins) for example eggs, meat, dahl and milk.
ENERGY GIVING FOOD (carbohy
drates and fats)-for example flour, rice
and sugar are carbohydrates and butter
and oil are fats.
& PROTECTIVE FOODS (vitamins
and minerals)—these are found in fruit
and vegetables.
These three types of food are all essential
to sustain life in amounts and proportions
that vary according to age, state of health and
other factors. Protein foods tend to be ex
pensive and are therefore often relatively
CASE STORY
LOBSANG'S STORY
Lobsang went into the small restaurant, sat at his
usual table and waitedfor his food to be served. They
were late today which annoyed him, like the flies buzzing
round all morning disturbing his concentration had
annoyed him. So many small things annoyed him these
days—no water last week then no electricity last night
when he was supposed to be finishing a piece of work
for that irritating woman who wanted everything done
the day before she ordered it. Then his sister's son had
written saying he needed money, reminding him that he
hadn't yet paid the boy's school fees.
The abrupt
arrival of a plate of rice and dahl interrupted his thoughts.
He didn't bother to look round to see who served it,
dkon mchog gsum, rice and dahl again I
He ira.t sick
of rice and dahl. All through his school years he'd
had to eat it and it hadn't stopped now.
Impatiently he
reachedfor the jar of chillie powder and ladled two spoons
on to the food. No taste, two more, plus some salt for
good measure. What had the doctor said ? Less salt
and chillie because the stomach aches that he had been
getting lately could be due to an ulcer and he should try
to eat less salt anyway so he didn't get high blood pressure
when he war older.
He pushed away the half eaten
plate, reached into his pocket and took out his last
cigarette. When he was older - ha 1 He was only twenty
three. When he was older he’d worry about those
problems then. Right now he had enough to worry
about anyway. As he flicked the ash from the tip of
the cigarette onto the plate he remembered guiltily that
the doctor had also told him that he should give up his
smoking. He knew she was right there - it cost him too
much, it upset his mother (whom he'd promised he would
give up), and it made him cough all the time and too
quickly out of breath when he played football with his
friends in the evenings.
Quite how smoking could also
cause his stomach aches he wasn’t sure, but she said it
did ....... and it too could cause high bio d pressure
and even cancer in the lungs and mouth.
Last week he
had caught his youngest brother smoking with his friends
which had made him inexplicably angry.
He had hit
him hard across the face, knowing as he did so that the
anger was partly directed at himself. Guilt for onvi role
in the boy's smoking and for not having been able to
give up.
His head ached. May be that was why he was in
such a bad mood today. Last night he'd had too much
to drink again. Well what else war there io do after
the electricity went off ? That was another thing
that he had promised his mother he would stop.
And
another cause of his stomach problems according to the
t doctor ! Quickly he tried to shut out the recollection of
the blood he had vomited up just that morning.
It
frightened him.
When his room mate had seen it he
had urged him to go back to the doctor. Lobsang had
told him to mind his own business and then he'd taken
two of those chalky white antacid tablets which were
supposed to help. They just made him feel more nauseated.
May be he would go to the doctor. He hoped it wouldn’t
be the same one he'd seen before, with her gratuitous
advice and chalky medicine which didn't help him.
Lobsang is not a real person. His story
is made up from the stories of many people
and it helps to illustrate how bad habits in
eating, drinking and lifestyle can combine
to cause health problems, in this case peptic
ulcer (see box). When he saw the doctor
that day (unfortunately for Lobsang it was
the same doctor 1), she was concerned that
lie had vomited blood and noticed that he
was looking \cry pale and had lost weight
since his first visit. She thought he probably ,
did have an ulcer and it was bleeding after !
having been irritated by the alcohol Lobsang ,
had drunk the night before.
i
I o properly diagnose an ulcer (he best i
method is to look down into the stomach
and upper intestine with a long tube called
a gastroscopc or endoscope. (Sec page 22 of
this issue.) If there is no endoscopy service
available then special x-rays using a white
substance called barium to outline the walls
of the stomach and intestine can be done.
The person swallows the barium then x-rays
are taken as the it passes down through
the gullet to the stomach and then the first
part of the small bowel. The white barium
shows up on the x-ray film and will outline
any defects in the walls of the intestine, such
as an ulcer.
If some one is found to have an ulcer
by endoscopy or barium x-ray, or if an ulcer
is highly suspected on clinical grounds, then
the best medicine to heal it, is a drug which
prevents acid secretion in the stomach;
such, as cimetidine or ranitidine. However
these drugs are expensive and need to be
taken for four to six weeks to heal the ulcer
and there is a high chance of relapse (i.e.
the ulcer coming back again). Occasionally
people need surgery to stop an ulcer bleeding
or to prevent it from recurring.
With peptic ulcer disease, as with many
other diseases, what we eat is important.
Other diseases which arc common amongst
Tibetans that arc directly or indirectly
related to what we eat and drink, (among
other things), are arthritis, diabetes, high
blood pressure and alcoholic liver disease.
Once these diseases are established allopathic
medicines can not cure them, neither pills
nor injections. Medicines can help people
to feel better and may ameliorate the cond^
tion while they are being taken, but then
they need to be taken continuously for many
years. The best cure is prevention. What
we eat and drink is our own responsibility
therefore our health as determined by our
diet and lifestyle is our responsibility. If we
eat, drink or live unwisely the health consequ
ences are ours.
Epigastric Pain and Peptic Ulcer Disease
Epigastric pain, or pain in the centre of
the upper abdomen often comes after eating
too much spicy or greasy food or drinking
too much alcohol. These make the stomach
produce extra acid
which causes a dis
comfort or burn
ing feeling in the
stomach. Frequent
or lasting epigas
tric pain is a
warning sign of
an ulcer.
An ulcer is a chronic sore in the stomach
or intestine, caused by too much acid. It can be
recognised by a chronic, dull (sometimes
sharp) pain in the stomach. Often the pai^
lessens when the person eats food or drinks
milk.
The pain gets worse 2 to 3 hours
after eating, if the person misses a meal, or
after drinking alcohol or eating chillie or
fatly foods. The pain is often worse at night.
If the ulcer is severe, it can cause vomiting,
sometimes with blood.
Stools with blood
from an ulcer are usually black like tar.
12
International Conference on Mental Peace and
Global Health
— Organized by the Department of Health, hosted by the Department of Health and Council for
Religious and Cultural Affairs.
—Dharamsala, November 12th—15th, 1930.
Three years ago, Mrs. Namgyal Lhamo
Taklha, (then Director of the Tibetan Medical
and Astrological Institute), was challenged to
host a conference on Mental Peace and
Global Health. In November this challenge
was realized when participants from 10
countries, plus many observers, met and
presented their individual or group views.
As reiterated by each speaker, the topic is
vast and open to many different interpreta
tions, of which their own could be a but a
tiny contribution - thus as the meeting progres
sed listeners were treated to wide range of
views ranging from the scientific and clinical
to the inter and inlrapersonal and we were
priviledged to be addressed by two very
learned Tibetan Buddhist scholars, Ven.
Khamtul Rinpoche and Ven.Lobsang Gyatso,
and others, on the Tibetan Buddhist philoso
phical approach to mental peace.
The conference was opened by Kalon
Kalsang Yeshi and welcome speeches were
made by Mrs. Namgyal Lhaino Taklha and
Mr. Moury (Belgium). The first session
then proceeded as follows :Dr. Dan Goleman (U.S.A.) spoke first
about the influence of emotions on health,
particularly about the advances in the past
decade in the field of immunology, linking
the functions of the immune system with the
brain and central nervous system and how
positive and negative psychological states
affect the immune system, and thus our health.
He was followed by Dr. Francois Majois
(Belgium), who gave a talk titled Cancer and
Psychology, which discussed the possible
influences of the psychological state on the
initiation, promotion, progression and finally,
treatment of the cancer process. Again the
role of the immune system in regulating
cancer growth was emphasised, with exciting
■implications for prevention by vaccination.
She finished by saying that much more
research needs to be conducted at all levels
before definite conclusions can be drawn.
Dr. Kim Jobst (U.K.) concluded the
first session with a very thought-provoking
talk where he asked us to consider disease,
mental and physical, as a manifestation
of health. Shifting our perception of illness
this way then permits us to see the “disease”
process as a perfect system striving to regain
its balance; to make use of suffering that is
inevitable and, as doctors and healers, to
help people more effectively.
The second day began with Dr. Myriam
'Leplat’s (Belgium) paper on Anxiety and
Panic Disorders, where she discussed how
problems originating or exaggerated psycholo
gically can be somatically, or physically,
manifested and interfere with normal daily
functioning. She was followed by Dr Barry
Kerzin (U.S.A.) who talked about Stress
Related Disorders and the Immune System —
the Approach of Behavioural Medicine and
INNER PEACE
“Be on the lookout for symptoms of inner peace. The hearts
of a great many have already been exposed to inner peace and
it’s possible that people everywhere could come down with it
in epidemic proportions. This could pose a serious threat to
what has, up to now, been a fairly stable condition of conflict
in the world.
“Some signs and symptoms of inner peace :
A tendency to think and act spontaneously rather than on
fears based on past experience.
An unmistakeable ability to enjoy each moment.
A loss of interest in judging other people.
A loss of interest in interpreting the actions of others.
A loss of interest in conflict.
A loss of the ability to worry -this is a very serious symptom.
Frequent, overwhelming episodes of appreciation.
Contented feelings of connectedness with others and nature.
An increasing tendency to let things happen rather than make
them happen.
Frequent attacks of smiling.
An increased susceptibility to the love extended by others, as
well as an uncontrollable urge to love them back.”
— quoted by Dr. Kim Jobst, Mental Peace and Global Health
Conference (source unknown).
MeditationTherapy. He explained the role of
Behavioural Medicine in the treatment of
psychosomatic disorders (such as headache),
the modification of health risk behaviours,
the maintenance of good health (i.e. disease
prevention) and the maintenance of the
immune system, and then went on to discuss
stress related illness and specific therapies
used in Behavioural medicine. He then
briefly outlined the use of Mindfulness Medi
tation (University of Massechussetts) in (he
treatment of chronic illness. Two important
points were made
The importance of'
motivation over the type of therapy used, and
the healthy or positive aspect of suffering,
in that it can lead to transformation.
The next session consisted of a talk by
Dr. Colin Butler (Australia) on Mental Peace
and Global Ecological Medicine and short.
presentations from the group from the. U.K..
who each made personal statements on the.
meaning of mental peace and global health
for them as individuals in relation to their.
lives and their work. Dr. Butler concentra
ted on the environmental and ecological
aspects of global healh, defining health as a
state of balance and a sustainable state of
mental and physical wellbeing (Maurice
King) and outlining the major global diseases
of nuclear pollution, ozone depletion, etc.
He stressed the importance of increasing
awareness of the urgency of these problems
that face us all.
The afternoon session of the second day
was devoted to Dr. Tenzin Chodrak (Tibet)
who spoke about Overcoming Torture, his
experiences during twenty one years of
imprisonment
in Tibet.
In a very
moving speech he outlined the extreme physi
cal and mental hardships and deprivations
suffered by prisoners and yet still asked us to
remember that all Tibetans in Tibet, not only
prisoners, are denied freedom of expression
and movement with suppression of the basic
human rights under Chinese rule.
He
attributes his extraordinary survival to the
practice of his faith combined with his
profound knowledge and use of the Tibetan
medical texts.
Prof. Dorjee Gyalpo closed the day with
a talk on the relationship between mind and
body according to Tibetan medicine.
On the third day all the speakers were
Tibetan. Ngawang Topchen, a young monk
from Drepung Monastery who recently came
to India, opened the first session with a
description of the current situation in
Tibet including the repression in the
monasteries and his arrests for involvement
in human rights demonstrations and sub
sequent treatment in prison. He again
reiterated the importance of a strong Buddhist
faith, both as a reason to continue to resist
16
Chinese rule in Tibet and the reason he was
able to withstand torture and imprisonment.
Next, Ven Lobsang Gyatso, Principal of
the Buddhist School of Dialectics, Dharamsala, spoke on the Buddhist Theory of Mind
Control. In an extremely interesting and well
illustrated talk he proposed that the modern
preoccupation with material and intellectual
development leads only to frustration and
unhappiness and that for greater mental
peace more emphasis needs to be given to
ethical development.
He outlined the
Buddhist approach to this -through a
balanced understanding and acceptance of the
law of cause and effect and Karma, the correct
mental attitude may be obtained and mental
illhealth due to self cherishment averted.
Dr. Tenzin Chodrak started the after
noon session with a talk on Mental Health
in Tibetan Medicine. He was followed by Ven.
Khamtrul Rinpoche speaking about Buddhism
and Health. Rinpoche began by talking
about health of the mind, explaining that once
we understand the real (dependent) nature of
mind we will be able to achieve equanimity
and peace of mind. He went on then to the
importance of taking care of the body (physi
cal health), through exercise, nourishing food,
relaxation, having good and sincere friends,
extending knowledge, and cultivating and
maintaining good communication with all
people, including those from other cultures.
Finally he was asked to speak to about his
own special healing powers and techniques
which he started to do in great detail much to
the delight of everyone present. Unfortuna
tely time ran out and the session had to be
concluded.
The fourth and last day of the conference
consisted of a tour of the Tibetan Medical
and Astrological Institute, conducted by
Mrs. Tenzin Chodon from their Research
Department, followed by another very
interesting talk on the History of Tibetan
Medicine by Mr. Jigme Tsarong, in which he
traced the independent development of
Traditional Tibetan Buddhist medicine
originating from the teachings of the Buddha
in 500-400 BC. As Buddhism died out in
India and Nepal but went on to flourish in
Tibet, so too did it’s medicine, particularly
the herbal pharmacology, which was preserved
and developed into the unique art of modern
Tibetan medicine. Mr. Tsarong predicts a
new age for the spread of Tibetan medicine
and sees it as a dominant force in world
healing in the 21st century. He concluded
with a brief introduction to the conceptual
framework of Tibetan medicine. Mrs. Namgyal
Lhamo Taklha closed the final session with a
talk on The Hedth Situation of the Tibetans in
Exile. Course participants had an audience
ERRATA
Vol. 4 No. I
with His Holiness the Dalai Lama in the
afternoon and then attended a special per- '
formance and dinner at the Tibetan Institute
of Performing Arts.
The relationship between mind and body
has fascinated man for centuries and is
probably better appreciated by eastern
medical systems, with their integral spiritual
relationships, than by western allopathic
medicine with it’s scientific basis, whid®
finds the concept of mind difficult to
define and quantify. However, increasingly
western scientific medicine is recognizing the
significance of the state and functions of
mind in all aspects of health and disease. This
conference provided an important opportunity
for medical professionals from Tibet, India
and Western countries interested in the
spiritual dimensions of health and healing to
get together and exchange ideas and informa
tion, and to learn from one another.
Summer 1990
There were two important printing errors in the previous issue of the Health Bulletin.
On the cover page, From the Directors Desk, the lines in capital type should read
PRIMARY HEALTH CARE IS AN ATTITUDE TO HEALTH WHICH CAN
BE LEARNED. (The word ‘to’ was omitted.)
On page 17, first column, line 30, in parentheses, should read :- The Department of
Health itself only came in to existence in 1981, not 1989 as written.
We also neglected to specifically acknowledge the source of some of the illustrations
for this issue, Dr. David Werner’s book, Where There is No Doctor.
‘"f’-noa/a
/’^'■'ara-ggOOS
■
3. Evaluation
B. P. Survey in Bylakuppe finds 23",, of over
30’s have high blood pressure.
Following the visit and health education
talks given by Dr. Barry Kerzin in January/
February 1990, the health staff at Bylakuppe
decided to increase public awareness about
the dangers of high blood pressure by
conducting a blood pressure survey. They
began by asking the camp leaders to call all
those over 30 years of age for a blood
pressure check up and announced the time for
each place. Coverage was not 100"£ because
there was no compulsion to attend the centres
where the checks were held (i.e. each camp in
the Old Settlement and two centres in the
New Settlement). Check-ups were done until
people stopped coming and health education
talks about high blood pressure were given
when large groups assembled. A total of
1398 people over 30 years of age were checked
and 320, i.e. 23%, were hypertensive on that
initial reading (diastolic blood pressure
greater than 100 mm Hg)—the latter were
rechecked and those with persistently high
B.P. advised to attend either the allopathic
or Tibetan medical doctors for treatment and
investigation.
(Some failed to go for
re-checking).
The staff involved feel that this type of
campaign, while not able to survey the whole
population, was definitely beneficial for the
interest and awareness it created. The
results obtained suggest that routine
annual B.P. checks should be done on all
Tibetans over 30 years of age to detect
“silent” high blood pressure which, if left
untreated, can lead to major health problems
later on. As with other health problems
22
prevention is better than detection once the
problem is established. It is important to
educate all Tibetans about the preventable
causes of high blood pressure, particularly
dietary factors (too much salt and too much fat
including butter), smoking and alcohol.
The staff in Bylakuppe involved in this
survey are to be congratulated' for their
initiative in undertaking and following up
this project. They arc also surveying toilet
hygiene, before and after health education.
(Many thanks to Nurse Pelmo-la for her
enthusiastic support for health promotion in
Bylakuppe and for supplying us with the
above information.)
Australian Medical Team Visits
Mundgod
Preliminary report
Led by Dr. George Tippett, an anaes
thetist from Melbourne, a six membered
medical team spent 14 days in Mundgod in
September/Octobcr this year. Their main
aim was to investigate the cause and prevale
nce of upper gastrointestinal problems (mainly
dyspepsia, or epigastric/uppcr abdominal
pain) in the monks of Drepung and Gaden
monasteries. To this end they conducted
general examinations of the monks and lay
people at both Lama Camps (total 770 exami
nations) including blood, stool & sputum
tests and endoscoped those who had signs
and symptoms of peptic ulcer disease. A
total of 280 endoscopies were performed, 50
of which were on lay people. Laboratory
samples were taken to London by the
gastroenterologist of the team. A full report
will follow once the samples have been analy
sed and results collated.
Upper gastrointestinal disease is an
important problem amongst many adult
Tibetans, causing a large degree of sickness
and possibly leading
to more serious
disease later in life. The most reliable way to
diagnose peptic ulcer disease is by endoscopy
(looking down into the stomach and intestine
with a flexible tube with a light source at the
end of it, called a gastroscope.) This techno
logy, while standard in most developed
countries, is expensive to set up and maintain
4.
in situations such as that of the Tibetan
refugees in India. So there is a great need
for the type of survey conducted by the
Australians, to delemine the extent and degree
of peptic ulcer disease and correlation of
gastroscopic findings with the signs and
symptoms that the patient presents with.
Studies such as this help to decide questions
about drug treatment protocols and the cost
effectiveness of establishing an endoscopy
service for Tibetans.
Disease Control
TB Control in South India
To improve compliance with TB treat
ment and provide better continuity of care
Dr. Passang Norbu, in Mundgod, will now
be in charge of all the TB control in the
South. Previously thirdline patients from the
Tibetan settlements in South India were
sent up to Dharamsala for investigation
and initiation of treatment. These patients
will now go to
Doeguling hospital
and receive all the services provided in
Dharamsala. This will entail considerably
less travel and hopefully improve patient
compliance with treatment.
Also as part of the effort to improve TB
control in the South, the hospital at Hunsur
will now have a TB ward, with Nurse Pelmo
from Bylakuppe acting as TB - Control - in
Charge for the present. Dr. Tenzin Gelek,
recently
appointed Medical Officer in
Bylakuppe, and Dr. Kalsang Phuntsok, from
Kollegal, will visit Hunsur regularly to super
vise the management of the TB patients and
Dr. Passang Norbu will visit 2-4 times a year.
Despite concerted efforts to control the
spread of TB amongst the Tibetan refugee
population in India, the incidence appears to
be increasing. This may be due to several
reasons — the introduction of new
and
unrecognized infective cases amongst newly
arrived refugees from Tibet (where the preva
lence of TB has been quoted as being as high
as 15%), the ongoing problem of the mobile
sweater seller population with their increased
risk and the difficulties associated with their
life style in establishing the diagnosis an<j|
maintaining proper treatment and other a;s
yet poorly understood or investigated factors
(including the possibility of genetically deter
mined poor resistance to the TB bacillus).
Again, the wide geographical separation of
the Tibetan communities in India is a factor.
By regionalising TB control in the south and
providing better inpatient services, it is hoped
to improve the case management aspect of
TB control. Case finding is another problem
and more attention will have to be paid to
this by prioritizing active case finding, includ
ing vigorous contact tracing.
Subject: Re: Vit. A
Date: Wed, 21 Nov 2001 11:34:42 +0000
From: "umesh kapil" <kapilumesh@hotniail.com>
To: sochara@vsnl.com
The guidelines are enclosed. The DNp report of ICMR would be soon sent to
you
kapil
File Name: Vita-recf-MOHFWf /
Vita-a
National Consultation on Benefits and Safety of Administration of Vitamin A
to Pre-school Children and Pregnant and lactating Women held at New Delhi on
29th and 30th September 2000.
This National Consultation was conducted to discuss the cumulative
scientific and epidemiological evidence on Benefits and Safety of
administration of Vitamin A to preschool children and pregnant and lactating
women. The aim was to provide objective guidelines to the Ministry of
Health and Family Welfare, Government of India for future direction with
respect to National Programme for Prophylaxis Against Blindness in Children
Caused due to Vitamin A Deficiency. The list of invited participants is
enclosed as Appendix I.
Conclusions and Recommendations
Issue: National Programme for Prophylaxis against Blindness in
Children
Caused Due to Vitamin A Deficiency (VAD): Past and Present
Status
and
changing profile of VAD and its current status.
1.
1.1
Conclusions of the Discussions on Scientific Presentations
1.1.1
In India, the magnitude of clinical VAD has declined significantly but
exists as a public health problem in scattered pockets.
1.1.2
The problem of clinical VAD varies from cluster to cluster within
selected districts.
1.1.3
There is a need for a careful evaluation of the current profile of
clinical VAD and the reasons for change in VAD profile in the country.
1.2
Specific Recommendations
1.2.1
The existing data on VAD should be analysed by independent groups of
Epidemiologists, statisticians, Nutritionists, Pediatricians,
Ophthalmologists and Obstetricians to assess the current status of VAD.
1.2.2
The National Programme for Prophylaxis against Blindness in Children
Caused Due to Vitamin A Deficiency requires re-examination and the time has
come that VAD control should be a part of the primary health care.
1.2.3
The National Programme for Prophylaxis against Blindness in Children
Caused Due to Vitamin A Deficiency should clearly define the quantifiable
outcomes of implementation of the programme.
1.2.4
Since,
multiple nutritional problems co-exist in the
same
population, while executing any programme to control them, a holistic
approach should be adopted for combating nutritional deficiencies and
vertical approach aimed at single nutrient should be discouraged.
2.
and
issue:
lactating
Administration
of
synthetic
vitamin
A
to
Pregnant
lot'10 .
Re: ViL A
11/22/01 9:22
Women
2.1
conclusions of the Discussions on Scientific Presentations
2.1.1
Pregnant and lactating women should be encouraged to improve their
overall
nutrition. Principles of consuming balanced diet with
diversification in food
items are necessary to maintain adequate
macro and micro-nutrient status.
2.2
Specific Recommendations
As part of comprehensive antenatal and postnatal care, women should be
screened
for night blindness.
If pregnant/lactating women
have night
blindness, they should be referred to physician in
the nearby Primary Health
Centre or any other health facility
for appropriate management. In view of the
potential toxic and
teratogenic effects of high doses of Vitamin A, pregnant
and
lactating women with symptoms of night blindness should be treated with
Vitamin A in dosage not exceeding 10,000 IU per day. They can be given
Vitamin A till symptoms of night blindness disappear.
2.2.1
2.2.2
For sustainable elimination of VAD, production and consumption of
Vitamin
A rich foods must be strongly promoted in the community,
particularly
amongst pregnant and lactating women and children.
3.
Issue: Administration of synthetic Vitamin A to children between 6
months60 months.
3.1
Conclusions of the Discussions on Scientific
Presentations
It should be recognised that the National Programme for Prophylaxis against
Blindness in children caused due to Vitamin A deficiency was initiated in
the country primarily to prevent blindness due to Vitamin A deficiency in
young children and not to control childhood mortality.
3.1.1
Overall improvement in nutritional status of children is essential to
reduce under five mortality and morbidity. This includes promotion of
breast-feeding, appropriate complementary feeding, strategies to reduce 1BW
babies and prompt treatment of childhood illnesses.
3.1.2
Administration of Vitamin A with measles or polio vaccines does not
interfere
with their sero-conversion rates.
3.2
Specific Recommendations:
3.2.1
Available data are not robust enough to persuade us to
recommend a policy
of Vitamin A supplementation for the purpose of mortality
reduction in children.
3.2.2
The current programme
recommendations
of
periodic
administration
of
Vitamin A, starting with measles vaccine at
9 months till 3 years of age should be persisted with.
3.2.3
To achieve optimal benefit of the National Programme for Prophylaxis
against
Blindness in
Children Caused Due to Vitamin A
Deficiency, high coverage
(> 90%)
of
the target population must be ensured (at least for first 2 doses
of Vitamin A).
3.2.4
Strengthening of routine immunization including measles vaccination
will be
an additional step to improve Vitamin A nutrition.
3.2.5
Screening for clinical symptoms and signs of VAD in children should
become a part of primary health care. All children with clinical VAD are
to be treated as per the standard schedule of Government of India under RCH
2 of 10
11/22/01 9:22
Re: Vit A
programme.
A suggestion was made that an "Expert Committee on Vitamin A" of
Epidemiologists, statisticians, Nutritionists, Pediatricians,
ophthalmologists and Obstetricians may be constituted to critically review
and re-analyse the complete data available from published studies/trials
conducted in India and abroad on the issues raised in this consultation.
This would help in giving future direction/strategy to be adopted for
implementation of National Programme for Prophylaxis against Blindness in
Children Caused Due to Vitamin A Deficiency (Annexure I).
with
4.1
Issue:
Pulse
Polio
linking
of
Synthetic
Vitamin
A
Administration
Immunization
Conclusions of the Discussions on Scientific Presentations
4.1.1
linking of Vitamin A with Pulse Polio Immunization (PPI) provided
different
experiences in the states of Orissa and Uttar Pradesh
(UP). In Orissa where the
operation was backed by the support of UNICEF and who, and the
staff gained the experience of administering Vitamin A through an earlier
round of campaign approach, the coverage rates were high. In up, where the
Vitamin A administration was linked to PPI without similar support or
prior
experience, the coverage rates were poor.
In Orissa, risk of immediate side effects attributable to Vitamin A
administration, such as fever, nausea and vomiting, was similar in
children
who received Vitamin A with oral polio vaccine and
those who did not (about
3%). However, unequivocal evidence does
not exist on possible long-term
consequences of increased intra
cranial pressure (presenting as bulging
fontanel).
4.1.2
4.1.3
linking of vitamin A administration to PPI should be avoided at this
juncture
when the country is on the verge of achieving zero incidence of
polio, in view
of
the
absence
of
information
on
the
long-term
consequences
of
Vitamin
A administration to young children, inconsistent
coverage rates and
the enormity of training requirements.
Instead,
strengthening the Vitamin
A coverage under the existing National
Programme for
Prophylaxis Against
Blindness
in
children
caused
due
to
Vitamin
A
Deficiency ,
was
considered
appropriate.
4.1.4
Taking cognizance of the fact that in some states ocular
manifestations of
Vitamin A deficiency are above the level of
public health significance, it was
suggested that alternative
strategies should be explored for improving vitamin
A coverage
instead of linking Vitamin A distribution with PPI.
4.2
specific Recommendations
4.2.1
to
Synthetic Vitamin A
PPI.
supplementation
should
not
be
linked
4.2.2
In areas where Vitamin A deficiency manifestations are high,
alternative
approaches may be explored for improving Vitamin A
coverage instead of
linking Vitamin A distribution with PPI.
3 of 10
Re: Vit A
1V22/01 9:3C
Issue:
Therapeutic
Administration
of
synthetic
vitamin
during
Measles, severe Protein Energy Malnutrition, Xerophthalmia and
Diarrhoeal
Diseases
5.
A
Specific Recommendations
5.1.1 All children with xerophthalmia should be given 2 doses of synthetic
Vitamin
A as per present schedule of Government of India under RCH Programme.
5.1.2. All
children
suffering from measles should also
be given
one dose of
Vitamin A, if he/she has not received it during the previous one
month.
5.1.3
on
All
cases
of
severe
Protein
W eight
for Age criteria or clinical
given one additional
dose of vitamin A.
5.1.4 No
suffering
Energy
Malnutrition
(based
nutritional signs) should be
additional
dose of
Vitamin A is required for
from
diarrhoea and respiratory tract infections.
children
Annexure I
It was suggested that "Expert Committee on Vitamin A" may consist of the
following members
1.
Dr. Padam Singh, Additional Director General, Indian Council of Medical
Research, New Delhi
2.
Dr. Arvind Pandey, Director, Institute for Research in Medical
Statistics, New Delhi
3.
Dr. Abhya indrayan, Professor and Head, Divsion of Biostatistics,
University College of Medical Sciences, New Delhi
4.
Dr. Rajiv Behal, Senior Grade Scientist, Department of Pediatrics, All
India Institute of Medical Sciences, New Delhi
5.
Dr. D.C.S. Reddy, Professor, Department of Preventive and Social
Medicine, Banaras Hindu University, Varanasi
6.
Dr. H.P.S. Sachdev. Professor, Department of Pediatrics, Maulana.Azad
Medical college. New Delhi
7.
Dr. K. Vijayaraghavan, Director Grade Scientist-I , National Institute of
Nutrition, Hyderabad.
APPENDIX I
National consultation on Benefits and Safety of Administration of vitamin A
to Pre-school Children and Pregnant and lactating Women held at New Delhi on
29th and 30th September 2000.
LIST OF PARTICIPANTS
4 of 10
1.
Dr.B.N Tandon
Director,
PSRI, Press Enclave Marg
Shekh Sarai-Il,
New Delhi - 110 017.
2.
Dr. Shanti Ghosh,
Consultant MCH,
5, Aurbindo Marg,
New Delhi.
3.
Prof. H.P.S. Sachdev
Department of Pediatrics
11/22/01 93C
R»: Vit, A
Maulana Azad Medical College
New Delhi 110002
4.
Dr. K. N. Aggarwal
D-115, Sector-36,
NOIDA-201301,
Gautam Budha Nagar,
Uttar Pradesh
5.
Dr. Deoki Nandan
Head,
Department of PSM,
S.N. Medical College,
Agra, Uttar Pradesh.
6.
Dr. Sanjiv Bhasin
Reader,
Department of PSM,
Delhi Public School Hostel,
Sector-30, NOIDA-201 301.
Gautam Budha Nagar, up.
7.
Dr. I. D. Sharma,
Principal,
Health i Family welfare Training Centre
Kangra, District Kangra,
Himachal Pradesh.
8.
Dr. Rajesh Kumar,
Additional Professor & Head,
Department of Community Medicine,
Post-Graduate Institute of Medical Educ
and Research (PGIMER), Chandigarh-160 012.
Dr. N.K. Arora
Additional Professor,
Department of Pediatrics,
Al IMS, New Delhi.
9.
10.
Dr. Panna Choudhary,
Deptt. of Pediatrics,
Maulana Azad Medical College,
New Delhi - 110016.
11.
Dr. Sunil Gomber,
Associate Profesor,
Deptt. of Pediatrics,
University College of Medical Sciences
SGTB Hospital,
Shahdara, Delhi-110 095
12.
Dr.Sandip Kumar Ray
Professor s Head
Community Medicine Deptt.,
Calcutta Medical College,
88,College Street
Calcutta - 700 073.
13.
Dr. Kumud Khanna
Director,
Institute of Home Economics,
J-Block, South Extension,
Part-I, New Delhi.
14.
Dr. Almaz Ali,
Room No.2,
NIHFW Guest House,
nifhw, New Mehrauli Road,
5 of 10
Re: Vit A
11/22/01 9:3S
Munirka, New Delhi.
15.
Prof. A. P. Dubey,
Depth, of Pediatrics,
Maulana Azad Medical college,
New Delhi.
16.
Dr. Kalyan Bagchi,
Director,
Nutrition Syndicate,
R-18, Hauz Khas, New Delhi.
17.
Dr. Indira Chakravarty
Dean,
All India Institute of Hygiene s Public Health
110, Chittaranjan Avenue
Calcutta - 700 073
Dr. Sushma Sharma
Vice President,
Nutrition Society of India,
Department of Foods and Nutrition
Lady Irwin College,
1, Sikandara Road, New Delhi.
18.
19.Dr. Maya Chaudhary
Prof and Head,
Department of Foods and Nutrition
College of Home Science,
Agricultural University,
Udaipur-313 003
20.Dr. Vinodini Reddy,
Nurition Consultant,
305 Arien Apts.
Panjagutta,
Hyderabad-500 482.
21.Dr. B. N. Saxena,
Emeritus Scientist,
ICMR Headquarters,
New Delhi.
22.Dr. Neeta Bhandari
Senior Grade Scientist
Advanced Centre of Diarrhoeal Diseases
Department of Pediatrics,
AlIMS, New Delhi.
23.Dr. A. Indrayan,
Professor,
Division of Biostatistics
University College of Medical sciences,
New Delhi-110 095.
24.Dr. Dinesh Paul,
Joint Director,
NIPCCD,
3, Siri Institutional Area,
Khaus Khas, New Delhi.
25.Dr. D. K. Agarwal,
Professor,
Department of Pediatrics,
Institute of Medical sciences,
BHU, Varanasi, up.
26.Prof. s. K. Kapoor
6ofl0
11/22/01 9:3S
A
Professor,
Department of Centre for Community Medicine
AlIMS, New Delhi.
27.Dr. Arwind Wadhwa
Professor,
Department of Foods and Nutrition
Lady Irwin College,
1, Sikandara Road, New Delhi.
28.Dr. D. C. S. Reddy,
Department of PSM,
Institute of Medical Sciences,
Banaras Hindu University,
Varanasi.
29.Dr. Rajiv Behal,
Senior Grade Scientist
Advanced Centre of Diarrhoeal Diseases
Department of Pediatrics,
Al IMS, New Delhi.
30.Dr. Shinjini Bhatnagar
Senior Grade Scientist
Advanced Centre of Diarrhoeal Diseases
Department of Pediatrics,
AlIMS, New Delhi.
31.Dr. T. Jacob Jhon,
439, Civil Supplies,
Godwon Lane,
Kamalakshi Puram,
Vellore-632 002.
32.Dr. umesh Kapil
Additional Professor,
Department of Human Nutrition,
All India Institute of Medical Sciences,
New Delhi - 110 029.
33.
Dr. Pardeep Khanna
Reader,
Dept, of PSM,
Medical College,
Rohtak.
Representatives from Indian Council of
Medical Research
34.Dr. Padam Singh
Additional Director General,
ICMR Headquaters
New Delhi,
35.Dr. Vijayaraghvan
Director Grade Scientist-I
National Institute of Nutrition,
Indian Council of Medical Research,
Jamai-Osmania PO, Hyderabad-500 007,
Andhra Pradesh.
36.Dr. Bhaskaram
Director Grade Scientist-I
National Institute of Nutrition,
Indian Council of Medical Research,
Jamai-Osmania PO, Hyderabad-500 007,
Andhra Pradesh.
37.Dr. Arvind Pandey
7 of 10
Rp-va a
11/22/01 9:44
Director
Institite of Research in Medical Statistics
ICMR Headquater Campus
Ansari nagar
New Delhi
38.Dr. T.C. Gupta
Assistant Director General,
Division of REN
Indian council of Medical Research
Ansari Nagar, New Delhi.
39.Dr. B. S. Dhillon,
Asstt. Directo General,
ICMR, Ansari Nagar,
New Delhi.
40.Dr. G.S. Toteja
Assistant Director General,
Division of RHN
Indian Council of Medical Research
Ansari Nagar, New Delhi
Representatives
from the Government of India and State Governments
41.Mr. Gautam Basu
Joint Secretary (RCH)
Ministry of Health and Family Welfare
Nirman Bhawan
New Delhi
Dr.V.B.
42.
Gupta
Deputy Commissioner
Ministry of Health and Family Welfare
Nirman Bhawan, New Delhi
43.
Dr. B. K. Tiwari
R.No.355
Adviser Nutrition,
DGHS, Nirman Bhawan,
New Delhi.
44.Dr. lalrintluangai,
Deputy Commissioner (RSS),
Ministry of Health i Family welfare,
Nirman Bhavan, New Delhi.
45.
Ms. Shashi Prabha Gupta
Technical Adviser,
Department of Women i Child Development
Shastri Bhawan,
New Delhi.
46.Dr. Sudhansh Malhotra,
Assistant commissioner,
Room No. 405, D Wing,
Ministry of Health and Family Welfare,
Nirman Bhavan, New Delhi.
47.Dr. V. Behal.
Assistant Commissioner,
Ministry of Health 4 Family welfare,
Nirman Bhavan, New Delhi.
48.
Mr. I. M. Sondhi,
Deputy Secretary,
11/22/01 9:44
8 of 10
Re: VILA
Room No. - 309, D-Wing,
Ministry of Health and Family Welfare,
Nirman Bhavan, New Delhi.
49.Dr.Abdullah Dustagheer
Project officer,-Nutrition
Child Development and Nutrition Section
*
73, Lodi Estate,
UNICEF, New Delhi.
50.Dr. Ashi Kathuria
USAID,
American Embassy
Shantipath
Chankyapuri
New Delhi -21.
51.Dr. Teresa Beemans
Director, MI south Asia,
Mocronutrient Initiative,
208 Jor Bagh,
Lodhi Road, New Delhi-110 003.
52.Dr. Sultana Khanum
Regional Adviser Nutrition,
WHO, searo, inderprastha Estate,
New Delhi.
53.Dr. Shiela Vir,
Project Officer, UNICEF,
14-B, Mall Avenue,
Lal Bahadur Shastri Marg,
Lucknow-226 001.
54.Dr. T. Walia
Vice Representative,
who India office,
Nirman Bhavan,
New Delhi.
55.Dr. Victor Barbiero
USAID,
US Embassy
Chanakyapuri,
New Delhi.
56.
Dr. Saraswati Bulusu
National Project officer,
Mocronutrient Initiative,
208 Jor Bagh,
Lodhi Road, New Delhi-110 003.
>From: Community health cell <sochara@vsnl.com >
>To: kapilumesh@hotmail.com
>Subject: Vit. A
>Date: Wed, 21 Nov 2001 17:00:49 +0530
>Dear Dr. Kapil,
>Please send us the Government of India guidelines for Vit. A
Administration circulated in September 2000 and any update. We would
Also be interested in the ICMP 18 districts study of Vit. A deficiency.
>Do you have any recent data from Karnataka?
OoflO
Re: ViLA
>Best wishes & Thanks,
>Thelma Narayan
Get your FREE download of MSN Explorer at http://explorer.msn.com/intl.asp
11/22/01 9:5C
Subject: Fwd: AJHRC blames State Govt & UNICEF: V lTamin A update
Date: Tue, 22 Jan 2002 04:12:30 -*-0000
From: 'uinesh kapir <kapiiumesivShotmaiI.com>
To: kapilumesh@hotniail.coni
mi
National Institute of Public Cooperation and Child Development
S.K. Muttoo
Director
3 I OCT 2001
Dr. Dinesh Paul
M.B.B.S., M.D., M.A.M.S.
Joint Director
NO.NI/CD/n/1145/NT-2001
Subject: Orientation Training Course on Best Practices in Community Nutrition
For Functionaries of Mother NGOs working for Maternal and Child
Nutrition.
(19-23 November, 2001)
Dear Sir/ Madam,
National Institute of Public Cooperation and Child Development announces a
course on on Best Practices in Community Nutrition for Functionaries of-Mother NGOs
Working for Maternal and Child Nutrition at its premises in New Delhi from 19-23
November 2001. The main objectives of the course are to orient the functionaries of
voluntary organizations to develop better understanding and insight into the fundamental
concepts in nutrition of children and women; to sensitise the participants to the best
practices related to nutrition prevalent in the community; and to equip them with the
necessary skills for improving the nutritional status of women and children by adopting
good practices. The Course has been designed for personnel for Mother NGOs working
for maternal and child nutrition.
We shall be grateful if you kindly nominate one or two officers from your
esteemed organisation engaged in implementation/planning of programmes of maternal
health and nutrition for participation in the above course. The medium of instruction for
the course will be English. The announcement giving the detailed information about
objectives, participants, contents and organisational/administrative aspects of the course
and a nomination form is enclosed herewith.
Nominations are expected to reach the Institute by/5th November 2001.
Looking forward to your cooperation and early reply.
Yours sincerely,
^Dinesh Pai
General Secretary
Cormnuni ty Heal th Cel I
367, Srinivassa Nilya
Jakkasandra I, Main I Block Koramangla
Bangalore - 560 034
Karnataka
5, rfrti
VtW fTn sra,
fccvft-110016. UR: EB. ^IRI: 091-011-6651349,
6963002,6963204.6969010.6967592
5, Siri Institutional Area, Hauz Khas, New Delhi-110 016. Telegram: NIPCHILD, Fax: 091-011-6851349, Phone: 6963002. 6963204, 6969010. 6967592
NATIONAL INSTITUTE OF PUBLIC COOPERATION AND CHILD DEVELOPMENT
5,
Siri Institutional Area, Hauz Khas, New Delhi - 110016
Phone: 6963002. 6963204, 6963378
Gram: NIPCHILD
E-mail:pauldinesh@vsnl.com
Nomination Form
Name of the participant
:
Age
Educational/Professional Qualification :
Designation & Present work Performed in the Organisation
Experience of Work
:
Complete Postal Address :
Name of Sponsoring Organisation :
Fax/Tel. No. /E- mail
No. of branches/field units
Brief description of activities of the organisations :
Problems/Issues the participant would like :
to discuss during the Course
Signature
For Sponsoring Organisation
I sponser the application of Shri
to participate in the
________
from I
Bank draft no
Director, NIPCCD, New Delhi is enclosed
Signature of Executive Officer
dated
to
for Rs in favour of
at NIPCC
Programme Announcement
Orientation Course on Best Practices
in Community Nutrition
for
Functionaries of Mother NGOs Working
for
Maternal and Child Nutrition
(19-23 November,2001)
National Institute of Public Cooperation and Child
Development
5, Siri Institutional Area, New Delhi-110016
Introduction
Nutritional Status of population particularly children,
is a crucial indicator in determining the quality of life of
people and is linked with their health status. India has
achieved marvelous increase in food production, yet her
nutrition problems continue to be formidable. Malnutrition
is still one of the critical issues deterring national
development. Nearly two-third of India's population is on a
nutritionally deficient diet. Nutritional surveys conducted
and repeated over a number of years have indicated that a
majority of population of every age group, including both
the sexes, suffers from malnutrition bordering on both
calorie and protein starvation and lack of protective foods
rich in minerals and vitamins.
Malnutrition affects people in general but its effects
are more pronounced among the vulnerable groups - women
and children in rural areas. Overall 52 percent of women
have some degree of anaemia-35 percent are mildly
aneamic, 15 percent moderately and 2 percent are severely
anaemic. The prevalence of anaemia is slightly higher for
breastfeeding women than for other groups. Malnutrition
has an adverse influence on morbidity, mortality and life
expectancy. It stunts physical growth and development of
children and leads to generalized functional impairment,
disability, diminished productivity and inability to cope with
environmental hazards including resistance to infection.
Based on International standards 47 percent of children age
three years in India are underweight; 46 percent are stunted
and 16 percent are wasted. The determinants of malnutrition
at different levels are many. At the macro level general
inadequacy of food, population growth, poverty etc. are
operative where as at individual level food, nutrient intake
and its utilization depends on factors like age, physiological
and pathological status of the person. Overlapping the micro
and macro factors , there are socio economic and cultural
factors like purchasing capacity of the family, family size,
food habits and beliefs, health aspects and environment,
which directly influence the diet of people.
Malnutrition is not exclusively due to non
availability of nutritious food but failure to use the available
resources in a meaningful manner is another cause. Lack of
information/ knowledge regarding the value of foods in
relation to the needs of the individual, ignorance and
superstitions play a great role in the rejection of locally
available cheap nutritious food. A majority of people, no
matter what class, has status symbols, which force them to
spend their income for purposes other than that of securing
food. Even when more money is spent on the food, it is
spent on the wrong type of foods. Solving the problem of
malnutrition, therefore involves not only having the food to
eat but also the proper selection, preparation and
consumption of food.
Infants and pre-school children constitute fifteen
percent of the total population of India. This group is most
susceptible to malnutrition, morbidity and mortality. Apart
from other causes, it is said that faulty feeding practices and
early weaning especially in urban areas are some of the
factors associated with high infant and child mortality in
India. Although breastfeeding is nearly universal in India,
very few children are put to breast immediately after birth-
only 16 percent in first hour and 37 percent on the first
day .It is well known that breastfeeding especially colostrum
feeding in particular is a life saving measure as it provides
protection to infants against infection. Infancy, particularly
the first six months is the most crucial period in child's
extero-gestate life. The practice in some cultures of
discarding colostrum and giving sugar water or honey
should be discouraged as it is harmful for the child.
Similarly, early weaning of the child from breast milk can
be very harmful for the psychological and nutritional well
being of child. NFHS surveys reported that the custom of
squeezing the first milk from the breast before breastfeeding
a child is widely practiced in India. Nearly two third of
women (63 percent) squeezed the first milk from the breast
before they began breastfeeding. It is more common in rural
areas and for children whose mothers are illiterate,
Scheduled tribe children, children whose mothers work on
the farm or in the family business. In 20 of 25 states the
mothers mostly discarded first milk. The only exceptions are
Tamil Nadu, Manipur, Bihar, Goa & Arunachal Pradesh.
Recently conducted NFHS surveys also show that
only 55 percent children under four months of age are
exclusively breastfed. At age 6-9 months, all children should
be receiving solid or mushy food in addition to breastmilk to
provide sufficient nutrients for optimal growth. However,
only 34 percent of children aged 6-9 months receive the
recommended combination of breast milk & solid or mushy
food. These figures are (15-18 percent) lower than national
average in six states including Bihar, Uttar Pradesh, &
Rajasthan.
For health of the young child & the pregnant women,
provision of adequate food during pregnancy and lactation,
new bom care, promotion and support of breastfeeding,
complementary feeding, growth monitoring with appropriate
follow up action and nutrition surveillance and disease
management etc. are some of the most essential needs.
Nutrition intervention programmes have been taken up and
are being implemented by central and State Governments
and voluntary organizations with a view to ameliorating the
nutritional status and health of the vulnerable section of
population. Deliberate and sustained nutrition education has
been recognized as a potent weapon for improving the
nutritional status of people as it is not a mere transfer of
knowledge but to motivate and bring about behavioral
changes among the community members in the choice of
foods.
Scientific studies in the field of nutrition and health
have generated substantial information on many aspects of
child growth, survival and development. However, one of
the major constraints experienced by the voluntary
organisations is with regard to lack of awareness on simple
but crucial issues related to best practices to be adopted by
community for proper nutrition & health care of women and
children:' It is therefore necessary to equip voluntary
agencies to incorporate new approaches in the area of
nutrition and health for managing their projects effectively
and disseminate scientific and correct knowledge in the area
of community nutrition and health.
In order to enhance the capabilities of functionaries
of voluntary organizations, the Institute proposes to organize
an Orientation Course on Best Practices in Community
Nutrition for Functionaries of Mother NGOs working for
Maternal and Child Nutrition from 19-23 November 2001.
Objectives
The main objectives of the course would be:
(i)
to orient the functionaries of voluntary
organizations to develop better understanding
and insight into the fundamental concepts in
nutrition of children and women;
(ii)
to sensitise the participants to the best
practices related to nutrition prevalent in the
community; and;
;.
(iii)
to equip them with the necessary skills for
. improving the nutritional status of women
and children by adopting good practices.
Participants
About 20 participants comprising officials and
middle level functionaries of Mother NGOs working in the
area of maternal & child nutrition from all over India
entrusted with the training field NGOs will participate in the
course.
Content
The content of the course would broadly cover
health and nutrition status of women and children: a review
of traditions and practices in infant feeding including
colostrum
feeding;
exclusive
breastfeeding
and
complementary feeding; nutrition during pregnancy and
lactation; supplementary feeding programmes for women
and children their utilization; common nutritional deficiency
diseases and prevention and management at household level;
prevalent myths and misconceptions;
gender equity;
innovations and demonstrations for behaviors change
through community based monitoring; ways and means to
replicate best practices and advocate for change and
demonstration of best practices.
Approach and Method of Training
Participatory methodology would be adopted during
training to build on experience, potentials and inherent
talent; provide sequential flow of learning; relate to real life
situation; and bring about flexibility in the learning process.
The various methods proposed to be used in the training
include lecture-cum-group discussions, case presentations,
demonstrations,
mock
sessions,
simulation
exercises,
practicum, group work and field visits.
The medium of communication in the course will be
English
Training Faculty
Experienced resource persons from NIPCCD as well
as external agencies will conduct the technical sessions.
The external resource faculty will be drawn from
government,
non-governmental
and
international
organizations dealing with maternal and child health. The
participants themselves are a valuable resource whose active
participation would determine the success of the course.
Review Sessions
Review sessions would be held throughout the training
through an in-built process. The basic objective of review
sessions at the activity and learning level would be to assess
the pace of learning and call for suitable modification in the
content and methodology; to assess gain in knowledge, skill
and change in attitude recall, retention and recapitulation
power; and at the organizational level of utilization material
resources, manpower and monetary investments.
The review sessions will be done every day through
discussion of day's report prepared by Day Officer
nominated by the group. Other methods for review will be
through quiz, presentations, mock sessions, etc.
Assessment and Evaluation
Pre and Post Testing Technique
A questionnaire specially designed to assess the
knowledge base as well as training needs at the entry and
gain in knowledge and fulfillment of educational objectives
at the end of the training will be used.
End Course Evaluation
The participants would evaluate the course on
parameters such as course content, duration, skills of
trainers and facilitators, training methods, training material,
logistics, etc. on a questionnaire designed for the purpose.
The information elicited would be a very useful tool for
planning and conducting future courses.
Resou rce Material
Resource material comprising handouts, training
module, case studies and other material to supplement
classroom teaching would be made available progressively
to the participants during the course.
Venue and Duration
The duration of the course will be of five days. It
will be conducted at the premises of National Institute of
Public Cooperation & Child Development (NLPCCD), New
Delhi from 19-23 November 2001.
Course Fee
The course fee would be Rs.3700/- for residential
participants and Rs.2500/- for non-residential, The fee
covers all expenses excluding cost of travel to and from the
Institute.
The fee is payable through demand draft drawn in
favour
of Director,
National Institute of Public
Cooperation & Child Development, New Delhi.
The demand draft should reach the Institute
alongwith the nomination form atleast two weeks before the
commencement of the programme.
Award of Certificate
The participants will be awarded a certificate of
participation on conclusion of the course.
General
The following general information may please be
noted:
i)
The enclosed nomination form of the
participant alongwith the course fee should
reach the Institute duly filled
formalizing
nominations
latest
in for
by
5th
November 2001.
ii)
The medium of communication in the course
would be English, voluntary organizations
may
ensure
that
their
nominees
can
comprehend English.
iii)
The minimum educational qualification for
nominees is graduation.
iv)
The Institute will have no responsibility
whatsoever towards board and lodging in
respect of family members/relatives/friends
of the participants, if any.
v)
Trainees will bear their own traveling cost.
Location
The Institute is located at 5, Siri Institutional Area,
Hauz Khas, New Delhi.
The campus of the Institute is
opposite Hauz Khas Police Station and close to the Asian
Games Village.
The Institute is situated an approximate
distance of 14 kms from New Delhi Station, 18 kms from
Delhi Railway Station, 10 kms from Nizamuddin Railway
Station and 19 kms. From Inter-State Bus Terminus,
Kashmere Gate.
Nomination in the enclosed form should be addressed to :
Dr. Dinesh Paul
Dr Neelam Bhatia
Joint Director
Course Director
National Institute of Public Cooperation and
Child Development
5,
Siri Institutional Area, Hauz Khas,
New Delhi-110016
Telephone 91-11-6963383, 6963204,
Fax:91-11-6851349,6865187
Gram : NIPCHILD
E-mail: pauldinesh@vsnl.com
Aggarwal
Evaluation of National Nutritional Anaemia Prophylaxis and Control Programme
in a rural area of Haryana.
Short title: Anaemia control programme evaluation
Dr. Arun Kumar Aggarwal, Assistant Professor
Prof. Raj esh Kumar, Professor and Head
Community' Medicine Department
Postgraduate Institute of Medical Education and Research
Chandigarh - 160 012
India
Address for correspondance:
Dr. Arun Kumar Aggarwal
Assistant professor
Community Medicine
Postgraduate Institute of Medical
Education and Research
Chandigarh - 160 012
India
Email Aggak63@glide.net, in
Aggarwal
Abstract
Background: Anaemia is a public health problem in India. To formulate area specific
strategies, periodic assessment of the magnitude of anaemia and related factors in the
community should be done.
Methods: Knowledge of 155 men and 223 women about anaemia was assessed.
Haemoglobin estimation of 206 women was done. Dietary intake for iron rich foods of
113 antenatal mothers by 24 hour recall was assessed in a rural area of Naraingarh block
in district Ambala, Haryana.
Results: Knowledge about inadequate food (85%) as cause of anaemia, and green leafy
vegetables(74%) to prevent it was high. Misconceptions that food like ghee can correct
anaemia exist. Knowledge of men about the magnitude of anaemia problem, initial
symptoms of anaemia and the services available to combat it was poor. Overall, 92.2%
women had anaemia of some degree. Mild anaemia (Hb 10.0 to 10.9 gms/dl) was present
in 28 (13.6%), moderate anaemia (Hb 7.0 to 9.9 gms/dl) in 157 (76.2%) and severe
anaemia (Hb < 7 gms/dl) in 5(2.4%) women. Major food items consumed were wheat
chapatis followed by rice and milk.
Conclusions: High prevalence of anaemia among women was observed. There were gaps
in knowledge and actual dietary intake of iron rich foods. Lack of knowledge about
locally available cheaper iron rich foods and gender gaps in knowledge needs correction.
Operational studies should be undertaken to improve compliance for better dietary intake
of iron rich foods and iron and folic acid supplementation.
Aggarwal
Introduction
Anaemia is one of the important public health problem all over the world, but much more
so in developing countries. Recent global estimates' suggest that over two billion people
worldwide are iron deficient with a global prevalence estimated at about 40 percent. The
prevalence was 51 percent for pregnant women, 48 percent for infants and one to two
year old children, 35 percent for non-pregnant women and 25 percent for pre-school
children. Prevalence in the sub-groups tend to be three or four times higher in developing
than developed countries.
Iron deficiency anaemia is more common in women because of regular loss of iron
during menstruation without adequate dietary compensation. Child bearing further raise
their need for iron. Maternal anaemia is associated with poor maternal outcomes like pre
term delivery, low birth weight, and maternal complications. Anaemia is one of the
commonest causes of maternal mortality, accounting for approximately 19% maternal
deaths. The problem is worst in India, where about 88 percent of pregnant women are
anaemic. Almost 60% of women are anaemic in other parts of Asia, but the proportion
does not exceed 40%> in China, Africa, or Latin America. Anemia affects 15% of
pregnant women in the established market economies 2. National family health survey
2000 revelaed that 52% of ever married women were anaemic in India3. Anaemia not
only contribute to high mortality and morbidity but also influence workers’ productivity
and activity pattern and thus has strong economic implications for any nation4.
3
Aggarwal
The breast milk of anaemic mothers is also iron deficient. Thus these infants grow and
develop in the environment of iron deficiency. It has been shown that iron-deficient
anemic infants are not as successful in tests of mental and motor development as their
iron-sufficient age-matched counterparts. A recent study has confirmed that iron
intervention can reverse developmental delays, while placebo-treated anemic infants
showed no such improvement5.
In India the commonest variety of anaemia is considered to be nutritional anaemia- due
to deficiency of iron. Iron and Folic Acid (IFA) tablets are being supplied to pregnant
women under National Anaemia Prophylaxis and Control Programme (NAPCP), which
is in vogue since the fourth five year plan period. Under this programme pregnant women
are given 100 mg of iron and folic acid tablets for 100 days during pregnancy as
prophylaxis and twice the above dose to women showing symptoms and signs of
anaemia. NAPCP is now integral part of Reproductive and Child Health (RCH)
programme. The effective coverage of this programme has remained about 30 percent of
the total eligible target group 6 and no perceptible change in incidence of low birth
weight, which is an important indicator of maternal nutrition, has occured in the last three
decades7.
Periodic assessment of the magnitude of anemia in the community and understanding the
operational problems in the anaemia control programme can facilitate in taking area
specific corrective actions. The present study was thus carried out with the objectives to
assess the knowledge of men and women about anaemia, to assess dietary intake of iron
Aggarwal
rich food and tab IFA during pregnancy and lactation and to assess the prevalence of
anaemia among married women in reproductive age.
Methodology
Study area-. Four villages around Naraingarh town in district Ambala, Haryana were
selected purposively so that these are conveniently located and easy to cover by the field
worker.
Study period'. The study was conducted in 1999-2000.
Study tools'. 1) knowledge assessment form to record the knowledge of men and women
about anaemia, its causes and consequences, signs and symptoms, prevention and
management and awareness of national programme to combat this problem, 2) form for
assessment of dietary intake of iron and medicinal supplements by pregnant mothers in
last 24 hours. Semi-structured interview schedules were used for knowledge and diet
assessment.
A trained field worker interviewed men and women and did haemoglobin assessment in
the 4 villages where home visits were made actively and in the surrounding villages
where periodic reproductive and child health camps were organised by our team in the
anganwaris of those villages. Knowledge about intake of iron during pregnancy and the
government services available for prevention and control of anaemia was assessed
among 155 men and 223 women. History of dietary intake of iron rich food, and
consumption of IFA tablets or any other iron preparations was taken from 113 antenatal
mothers by using a semi-structured interview schedule. Haemoglobin estimation to detect
anaemia was done among 206 women by Sahli’s method from the capillary blood.
Aggarwal
Diet assessment
Dietary history of intake of iron rich foods was taken from 113 pregnant women in the
rural areas using a semi-structured interview schedule. Women were asked whether they
had consumed any of the listed foods in last 24 hours at breakfast, lunch or dinner.
Proportion of women having consumed the listed food-items atleast once during last 24
hours was assessed.
Food items were categorised into five groups. Group one consisted of cereals like wheat,
rice and bajra; group 2 had pulses like blackgram, redgram, bengalgram, soyabean,;
group 3 had green leafy vegetables, green vegetables, fresh fruits and dry fruits; group 4
had meat, liver and fish and group 5 had milk. Scoring system was developed for further
analysis. Score of one was given if a particular food was taken one time during a day, a
score of 2 for consumption twice a day and score of 3 for consumption three times during
the day. By considering appropriate mix of diet it was calculated that a balanced diet
should have minimum score of 12(cereals 3, grams/meat 2, fruits 1, vegetables 3, milk
and jaggery 3). Mean and median score for intake of each food-group and for total food
intake was calculated. Total food score was grouped into four categories; group one with
zero score, group 2 with score of 1-5, group 3 with score of 6-10 and group 4 with score
of 11 and more.
6
Aggarwal
Ethical Justification
The project was approved by the ethical research committee of the institute. The project
involved assessment of knowledge, and blood testing for haemoglobin estimation.
Consent of the women was taken before taking blood sample. Blood was withdrawn by
following aseptic techniques through finger pricks. Confidentiality of individual
assessments was maintained. Subjects were free to leave the study at any time. Consent
of village leaders was taken before initiating the study.
Results
A total of 378 subjects were administered knowledge assessment questionnaire; 155
(41%) were men and 223 (59%) were women. Majority did not understand the question
that what is anaemia? Therefore, they were told in local dialect that “Khoon ki
kami”(deficiency of blood) is called anaemia. This local dialect was used in place of the
word ‘anaemia’ in subsequent questioning. Inadequate food (85%), excessive blood loss
(19%), illness (42%), worm infestation (4%) and child bearing (10%) were the major
causes of anaemia reported by respondents. Two respondents told that anaemia can occur
due to bad hygiene. Knowledge about inadequate food intake and worm infestation as
causes of anaemia, was not significantly different sex-wise. However, more of women
compared to men knew that excessive blood loss and child bearing can cause anaemia
(p<0.01). Some subjects responded that tubectomy (3), smoking (2), and mental tension
(10) can also cause anaemia (table 1).
Aggarwal
Seventy-four percent of subjects knew that green leafy vegetables should be taken to
prevent anaemia. Other foods known to them were: pulses (25%), poultry (22%), meat
(21%), jaggery (12%), nuts (11%), fish and cereals (2% each) and legumes (1%). The
sex-wise differences in knowledge were not significant. Other foods that can prevent
anaemia as told by respondents were: milk and ghee (37), fruits (27), milk and fruits (21),
ghee and fruits (13) and good diet and medicine (11) (table 1).
Tiredness as a symptom to suspect that a person is suffering from anaemia was known to
67% respondents. This knowledge was significantly more among women (72%)
compared to men (59%) (p<0.01). Twenty-five percent reported breathlessness and 60%
knew that paleness over face I nail I eyes can occur in anaemia. This knowledge was
more in men (78%) compared to women (47%)(p<0.01). Fifty-three percent respondents
knew that there is a go
-gramme to control anaemia. Significantly more women
(65%) knew about this compared to men (34%) (p<0.01). However, there were no
signific. ’
sex differences in knowledge that some tablets are available for control of
maemia, as told by 51% respondents. More women (40%) than men (29%) knew that
these tablets can be obtained from health centres (p=0.02). The knowledge that pregnant
women can obtain these tablets from health centres was also high among women (80%)
compared to men ( 58%) (p<0.01). Other beneficiaries who can get these tablets from
health centre, as known to respondents were lactating mothers (22%), family planning
clients (27%) and children (26%)(table 2).
Aggarwal
Sixty-four percent subjects knew that women can suffer most from anaemia out of men
and women. Significantly more women (76%) were of this opinion compared to men
(46%) (p<0.01). Nineteen percent responded that there are equal chances of getting
anaemia among both men and women, whereas, 5% considered that men suffer most
from anaemia. Significantly more males (p<0.01) were of the above opinions (Table 3).
Fifty-six percent respondents knew that if anaemia of a pregnant mother is not corrected,
she may die during delivery. Significantly more men (72%) knew about this compared to
women (45%) (p<0.01). Fifty-seven percent subjects knew that she may deliver a Low
birth weight baby. There was no significant gender difference in this aspect of
knowledge. Twenty-five percent respondents, and significantly more women (40%)
compared to 3% men (p<0.01), thought that consumption of iron tablets during
pregnancy may lead to difficult delivery(table 3).
Haemoglobin estimation was done among 206 women. Overall, 190 (92.2%) had
haemoglobin level less than 11 gm/dl. Mild anaemia (Hb 10.0 to 10.9 gms/dl) was
present in 28 (13.6%), moderate anaemia (Hb 7.0 to 9.9 gms/dl) in 157 (76.2%) and
severe anaemia (Hb < 7 gms/dl) in 5(2.4%) women. Mean, median and mode
haemoglobin was 8.84 gms/dl (SD 1.18), 8.5 gms/dl and 8 gms/dl respectively(table 4).
All women had taken atleast one iron rich food in last 24 hours. However, 100% had
taken cereals, 72% consumed pulses,68% took vegetables and fruits, 1% took meat and
63% had consumed milk atleast once during last 24 hours. It was observed that mean
score for intake of iron rich food was 6.9(SD 2.3) and median score was 7. Thus median
9
Aggarwal
score was 58.3% of the total food score 12 of the balanced diet. All women consumed
one or the other iron rich food. Twenty six percent had food score of 1-5, 69% had food
score of 6-10 and 5% had food score of 11 and above. Maximum consumption was of
food group one with mean score of 3.3 (SD 0.7), followed by foodgroup 3 (mean 1.3, SD
1.2) and food group 2 (mean 1.1, SD 1.0). Major food items consumed were chapatis
(median 3), Rice (median 1) and milk (median 1). In last 24 hours, everyone had
consumed chapatis, 65.5% had taken rice, 68.1% had taken green leafy vegetables or
green vegetables or fruits or jaggery, 62.8% had consumed milk and 0.9% had taken
meat or liver or fish altleast one time (table 5).
Discussion
The prevalence of anaemia among women is high in India. This can be due to less intake
of dietary iron, presence of inhibitors of iron absorption in the diet, and lack of iron
supplementation during specific physiological periods of physical growth and high
nutritional requirements. Although, relative contributions of these factors may vary in
different communities, but in poor populations of developing countries all the listed
factors are important contributors to anaemia. Lack of correct knowledge about the diet
and importance of iron supplementation during pregnancy, lactation and childhood may
be the underlying causes of low iron intake. Economic inaccessibility could be another
reason for this.
The present study was carried out to assess the magnitude of anaemia among married
women, and to find the knowledge of subjects about causes, consequences and prevention
of anaemia. Further exploratory analysis was done to find gender gaps in the knowledge
10
Aggarwal
and practices about dietary intake of iron rich foods. Assessment of knowledge was done
for both men and women and haemoglobin tests and dietary intake was assessed for
pregnant women during home visits in four villages initially, which was later extended to
camp based interviews in the villages around Naraingarh. As knowledge assessment form
could not be filled for all pregnant women, linkage of knowledge with practices could not
be established on one to one basis. Thus, results presented in this study provide
community based evidence of gaps in knowledge and practices and thus need to be
interpreted cautiously.
In our study the prevalence of anaemia among women was very high. Ninety-two percent
women had anaemia of some degree. Mild anaemia was present in 13.6%, moderate in
76.2% and severe anemia was present in 2.4%. WHO classification was used to classify
anaemia. However, due to lack of information about the pregnancy status in some, the
cut-off point for classification of mild anaemia was taken as < 11 gms/dl. Thus,
prevalence of anaemia will be even higher than this, considering the higher cut-off point
of 12 gms/dl for classification of mild anaemia for non-pregnant women, as per WHO
definition. Our findings are comparable to the other experiences in the country. In a
hospital based 8 study amongst 829 women of find and Hird trimester at Rural Health
Training Centre, Najafgarh, New Delhi, prevalence of anaemia was found to be 78.8%.
In a study in a hill sub-divison 2249 delivery cases were observed over a period of 4
years. All the cases were anaemic. Severe anaemia was noted in 3% cases, moderate in
21% and mild in 76% cases9. In a study on 93 married adolescent girls of scheduled
caste communities in rural Rajasthan 10 prevalence of anaemia was found to be 78%. In
Aggarwal
tribal blocks of Udaipur district, 94.4% (51/54) of adolescent pregnant girls in second and
third trimester, were suffering from moderate to severe anaemia 1'. As per NFHS-2
survey, 52% women had some degree of anaemia. Thirty-five percent were mildly
anaemic, 15% had moderate anaemia and 2% had severe anaemia3.
The prevalence of iron deficiency anaemia (IDA) in a population survey in Zimbabwe
was 33% among pregnant women, 29.6% among lactating women and 16.5% among
adult males. Serum ferritin levels were low in 9.1% of the population. More of the
pregnant women (14.8%) had iron depletion, compared to adult males (2.2%). It was
observed that individuals in regions with food insecurity were much more affected by
iron depletion and IDA than their counterparts in other regions 12.
Knowledge that less intake of iron rich foods can cause anaemia was found to be
satisfactory in our study. However, their understanding about other possible causes of
anaemia like excessive blood loss, child bearing, worm infestation and other illnesses
■was poor. Knowledge of men about female related causes of anaemia like excessive
blood loss and child bearing was significantly less. This gender gap in the knowledge
may have important bearing on the prevalence of anaemia in the country. In Indian rural
community set-up the woman in child bearing age usually does not decide about the
number and timing of children. Decision of in-laws and husband prevail to produce
children at short intervals. It further worsen the status of anaemia in women due to
inadequate iron supplementation and dietary compensation. Status of women
empowerment was assessed in NFHS-2 survey by asking whether the women needed any
12
Aggarwal
permission to meet their relatives or friends. The data revealed that only 24.4% women
didn’t need any permission to visit any friends or relatives. The data also revealed that
45% of the births in past 3 years were of the birth order of 3 or more and 46.9% had
desire for son for the next child 3. This indicates that women in child bearing age in India
do not decide independently about their choices and son syndrome puts them on the
morbid trap of repeated fertility.
Three- fourth of the total study subjects knew that green leafy vegetables (GLV) should
be taken to prevent anaemia. Knowledge about other locally available sources of iron like
pulses, jaggery, poultry, meat, fish, cereals and legumes was poor. Diet assessment
survey among 113 pregnant women revealed that all of them had had chapatis in last 24
hours. However, consumption of other iron rich foods like pulses, GLVs, jaggery and
meat etc. was poor. Seventy-two percent had consumed pulses, 68% had taken vegetables
or green leafy vegetables, 0.9% had consumed meat etc atleast once during last 24 hours.
Median score for food intake was 7, which was 58% of the total score of balanced diet,
indicating that almost hal f of the women had consumed about 50% of the requisite iron.
Other observations in Haryana support our findings. In a study conducted in 3 districts of
Haryana 13 mean daily intake of rural lactating women during summer season was
assessed. Percent recommended dietary consumption (RDA) was calculated using ICMR
nonns. It was observed that 76-97% women in the three districts had consumed cereals
and millets as per RDA, pulse consumption was 26% in Hisar, 29% in Bhiwani and 53%
in Kurukshetra, consumption of GLVs was conspicuously zero in all the three districts.
13
Aggarwal
Consumption of roots and tubers was 57-64%, other vegetables 46-51%, milk and milk
products 156-194%, fats and oils 90-121% and sugar and jaggery consumption was 62-
88% of RDA. Overall nutritional intake of iron was 27% of RD A in Hisar, 32% in
Kurukshetra and 51% in Bhiwani. Mean percent intake of iron in the three districts was
36.7%. Consumption of ascorbic acid was below 5%. As per NFHS-2 data, 37.5% of
ever married women consumed milk or curd, 46.9% consumed pulses or beans, 41.8%
took green leafy vegetables, 65.1% had other vegetables, 8.1% took fruits, 2.8 consumed
eggs and 5.8% had chicken, meat or fish daily. Consumption of these food items once a
week was near 100% in Haryana3. Study in rural Rajasthan also revealed that diets were
deficient by 39-55% for iron intake l0. In Najafgarh study, 85% of pregnant women were
consuming less than 50% of the iron compared to their RDA 8.
However, a study in Parbhana district14 showed that despite optimal intake of dietary
iron, prevalence of moderate anaemia among lactating women was very high. Mean
haemoglobin level in urban area was 9.21 and in rural area was 8.87 gms /dl. Moderate
anaemia with haemoglobin 7-<10 gms /dl was present in 94% urban and 97% rural
lactating women. The mean dietary intake of iron was 34.6(SD 7.7) in urban and 35.7
(SD 8.4) in rural area against RDA of 30mg. The mean intake for cereals was 73% of
RDA (300/410), pulses 87% (35/40), GLVs 75% (75/100), other vegetables 75% (30/40),
roots and tubers 62% (31/50), milk and milk products 120% (120/100), fats and oils
100% (20/20), and sugar and jaggery 90% (18/20) of the RDA in the rural areas. This
could be because of the reason that anaemia in lactating period is the cumulative effect of
14
Aggarwal
nutritional status in childhood, adolescence and pregnancy and thus cannot be corrected
immediately by dietary intake, which is just optimal for a non anaemic lactating woman.
Various studies in India show that iron deficiency and anaemia exist in adolescence and
pregnancy. A study conducted in 150 young women studying in Panjab Agriculture
University Ludhiana 15 showed that iron consumption during summer and winter was
13.4(SD 0.3) and 15.6 (SD 0.3) mg/day and was only 48% of the RDA of ICMR. The
mean haemoglobin level was 11.3(SD 0.11). On the basis of haemoglobin, 62% subjects
had anaemia (HB <12 gm/dl). None of them had Hb < 7gm/dl and only 2% had clinical
signs of anaemia in the form of pale conjunctiva indicating high incidence of subclinical
iron deficiency in this age group.
Indian rural diet is thus generally cereal based and lacks other iron rich foods. Pulses and
meat are costlier items and everyone cannot afford these. However, significant gap exists
even for other cheaper locally available foods like GLVs and jaggery. Despite high level
of knowledge about GLVs, intake was very poor. Both knowledge and intake were
deficient for jaggery.
Adequate iron supplementation during pregnancy and lactation can still lessen the
prevalence of anaemia. However, consumption of iron tablets by pregnant women is
usually low and compliance rate for intake of iron tablets is usually poor. Ln our study
only 24% of women had taken 90 or more tablets. Whereas, as per the national nutritional
anaemia prophylaxis and cbntrol programme pregnant women should take atleast 100
15
Aggarwal
tablets during pregnancy and double the dose is recommended for anaemic women. In
our survey, 92.2% of the women were anaemic with haemoglobin below 11 gm/dl. Thus
coverage of iron supplementation was poor in this area. Similar observations have been
made under NFHS-2 survey3. Only 57.6% mothers had received any tab IF A during
pregnancy and 54.2% had received sufficient supply of tab IFA or syrup in the two most
recent births. In another study 16 in rural area of Haryana 33.1% mothers reported having
pallor during their pregnancy, and only 14% had received prophylactic iron and folic acid
tablets for more than 90 days. A study in Andhra Pradesh among 8000 respondents
including 487 pregnant women found that 19% pregnant women had received folifer
tablets and 1% children were receiving these tablets. Health functionaries were not aware
of all the beneficiaries under the programme l7.
Although, there can be several causes of fatigue. Depressed patients feel fatigued on
arising to face the day. Patients recovering from infectious mononucleosis or viral
hepatitis feel strong in the morning but tire later in the day. Patients who have chronic
fatigue syndrome are tired all day long. However, fatigue of anaemia has its own face.
Patients with mild or moderate anaemia generally feel normal at rest and note fatigue
only with exertion 18. In our study, knowledge about tiredness as a symptom of anaemia
was assessed . Significantly more women knew that tiredness is a symptom of anaemia,
whereas, more men could tell that breathlessness and paleness over face/nails/eyes can
occur in anaemia. Overall knowledge about breathlessness as a symptom of anaemia was
low. The knowledge that women suffer more from anaemia than men was also higher
among women. However, knowledge about complications of anaemia like if anaemia of
16
Aggarwal
pregnant women is not corrected she may die during delivery was more among men. The
data thus indicates that men are more knowledgable about severe illness (breathlessness
and maternal death due to anaemia). However, they underestimate the magnitude of the
problem as they donot think that women suffer more from anaemia. Knowledge of
women was found to be more for subtle signs of anaemia and iron deficiency like
tiredess. They also knew that women suffer more from anaemia.
Summarising, prevalence of anaemia in pregnant women in this area is very high.
Knowledge about green leafy vegetables for prevention of anaemia is high but its
consumption is negligible. Knowledge about other appropriate locally available low cost
foods like jaggery, and other relatively high cost foods like pulses and meat etc. is low.
Iron supplementation during pregnancy despite knowledge of availability of iron tablets
from health centres is poor. Knowledge of iron supplementation for lactating women,
family planning clients and children was poor. Knowledge of men about magnitude of
anaemia problem and the signs and symptoms with which they generally suffer was poor.
Thus future research and health programmes should aim to eliminate the gender gap in
knowledge, promote male responsibility and bridge the gap between knowledge of
appropriate food consumption and its actual intake.
17
Aggarwal
References
1.
Ramalingaswamy V. Child’s right to nutrition medical and health perspective. The
Ind J Nutr Dietet 1999; 36: 123-126.
2.
World Bank. World development report 1993. Investing in Health. NewYork: Oxford
University Press, 1993.
3.
International Institute for Population Sciences. National Family Health Survey II.
Women and Reproductive Health India 1998-1999. Mumbai : International Institute
for Population Sciences, 2000.
4.
Edgerton VR, Gardner GW, Ohira Y, Gunawardena KA, Senewiratne B. Irondeficiency anaemia and its effect on worker productivity and activity patterns. Br
Med J 1979;2:1546-9.
5.
Sheard NF. Iron deficiency and infant development. Nutrition Reviews 1994 ;52:137-
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Goverment of India. Annual Report 1993-94, Ministry of Health and Family
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Aggarwal AK, Kumar R. Low birth weight prevalence and antenatal care practices in
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Kapil U, Pathak P, Tandon M, Singh C, Pradhan R, Dwivedi SN. Micronutrient
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Ray A. Difficulties in obstetrics practices in a hill sub-division. J Indian Med Assoc
1996; 94: 131-2, 142.
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Chaturvedi S, Kapil U, Bhanthi T, Gnanasekaran N, Pandey RM. Nutritional status of
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married adolescent girls in rural Rajasthan. Indian J Pediatr 1994; 61: 695-701.
Sharma V, Sharma A. Health profile of pregnant adolescents among selected tribal
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populations in Rajasthan, India. J Adolesc Health 1992; 13: 696-9.
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deficiency anaemia in pregnant and lactating women, adult males and pre-school
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Meena J, Vijaya N and Reddy SN. Food and nutrient intake, anthropometric
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Vijayaraghavan K, Brahmam GN, Nair KM, Akbar D, Rao NP. Evaluation of
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EichnerER. Fatigue of anaemia. Nutrition reviews 2001; 59: S17-S19.
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Table 1
Knowledge about causes of anaemia and iron rich food
Knowledge parametres
Men
(n=155 )
no. %
Women
(n=223 )
no. %
Total
(n= 378)
no. %
P
190
323
0.86
What are causes of anaemia?
Inadequate food
133
85.8
85.2
85.4
Excessive blood loss
16
10.3
57
25.6
73
19.3
<0.01
Due to other illness
87
56.1
75
33.6
162
42.8
<0.01
Worm infestation
5
3.2
10
4.5
15
4.0
0.53
Child bearing
0
0
40
17.9
40
10.6
<0.01
158
70.9
281
74.3
0.06
What foods should be taken to prevent anaemia?
Green leafy vegetables
123
79.4
Pulses
28
18.1
67
30.0
95
25.1
<0.01
Jaggery
9
5.8
40
17.9
49
12.9
<0.01
Cereals
2
1.3
7
3.1
9
2.4
0.41
Legumes
2
1.3
2
0.9
4
1.8
0.88
Nuts
6
3.9
36
16.1
42
11.1
<0.01
Liver
9
5.8
21
9.4
30
7.9
0.20
Meat
46
29.7
35
15.7
81
21.4
<0.01
Poultry
51
32.9
33
14.8
84
22.2
<0.01
Fish
7
4.5
3
1.3
10
2.6
0.11
20
Aggarwal
Table 2
Knowledge about signs/symptoms and national programme guidelines for control of
______________________________anaemia________________
Knowledge parametres
Men
Women
Total
(n= 155 )
(n=223 ) (n=378 )
no. | %
no. % ... no. %
How can you suspect that a person is suffering from anaemia?
Tiredness
92
59.4
161
72.2
253
66.9
P
<0.01
Breathlessness
38
24.5
57
25.6
95
25.1
0.81
Paleness over face/nails/eyes
122
78.7
106
47.5
228
60.3
<0.01
Knowledge about provisions under national programme for control of anaemia
53
34.2
147
Tablets available
76
49.0
Tab. available in health centres
45
29.0
Govt, programme available
65.9
200
120
53.8
90
40.4
180
80.7
52.9
<0.01
196
51.8
0.36
135
35.7
0.02
270
71.4
<0.01
Who can obtain these tablets from health centres?
Pregnant mothers
90
58.1
Lactating mothers
27
17.4
58
26.0
85
22.4
0.04
Family planning clients
44
28.4
61
27.4
105
27.7
0.82
Children
45
29.0
54
24.2
99
26.1
0.29
Who suffer most from anaemia?
Man
19
12.3
2
0.9
21
5.5
<0.01
Woman
72
46.5
171
76.7
243
64.2
<0.01
Equal chance in man or woman
47
30.3
28
12.6
75
19.8
<0.01
21
Aggarwal
Table 3
Knowledge about complications of anaemia
Knowledge parametres
Men
Women
Total
(n=155)
(n=223)
(n=378)
no. | %
no. 1 %
no. %
What can happen if anaemia of a pregnant mother is not corrected?
P
She may die during delivery
112
72.3
102
45.7
214
56.6
<0.01
She may deliver a low birth
82
52.9
135
60.5
217
57.4
0.13
weight baby
Do you agree that by consuming iron tablets during pregnancy, delivery become
more difficult?
Yes
6
3.9
90
40.4
96
25.3
<0.01
No
14.8
95.5
131
58.7
279
73.8
<0.01
22
Aggarwal
Table 4
Haemoglobin status of women
Haemoglobin group
Number (n=206)
Percent
(gms/dl)
<7
5
2.4
7- <10
157
76.2
10-<11
28
13.6
11 and above
16
7.8
23
NvTKARNATAKA STATE AGRO CORN PRODUCTS LTD.
Hebbal, Bangalore-560 024.
List of Directors of the company
1. ■ ' Dr. A. Ravindra' I.A.S.,
Chairman
Additional Cheif Secretary &
Development Commissioner,
Govrnment of Karnataka,
Vidhana Soudha, Bangalore-560 001.
2.
Shri T.R. Raghunandan, I.A.S.,
Managing Director
Karnataka Agro Industries Corporation Ltd.,
Hebbal, Bellary Road, Bangalore-560 001.
Managing Director
3.
Shri T.M. Vijaya Bhaskar I.A.S.
Commissioner for Public
Instruction in Karnataka
New Public Office Buildings.
K.R. Circle, Bangalore-560 001.
Director
4.
Smt. V. Vidyavathi
Director, Women & Child Welfare Department
1st Floor. M.S. Building,
Dr. Ambedkar Veedi, Banglaore-560 001.
Director
5.
Shri Sadashivaiah I.A.S.
Director of Food & Civil Supplies
Govt, of Karnataka, 5th Floor, No. 8,
Cunningham Road, Bangalore-560 052.
Director
6.-
Shri H R. Puttaraju
Additional Secretary to Govrnment
Agriculture & Horticulture Department
4th Floor, Muitistoreyed Building,
Dr. Ambedkar Veedi, Bangalore-560 001.
Director
7.
Shri T.R. Prabhu
Scientist, Technology Transfer &
Business Development, Central Food
Technological Reasearch Institute, Mysore
Director
8.
Shri M. Lokaraj
Deputy Secretary, Energy Deparment,
7th Floor, M.S. Building, Bangalore-560 001.
Director
E)
Weaning food units:
KARNATAKA STATE
AGRO CORN PRODUCTS LIMITED.
Registered Office
Phone Nos.
Office
Residence
8.
Shri T.R. Srinath
Dy. General Manager (WF)
KSACP Limited, Weaning Food
Unit No. 15, O.T.C. Post .Industrial Area,
914-22327 2221772
Doddaballapur
9.
Shri M.K. Nagaraja
Manager
KSACP Limited, Energy Food Unit
9C/10, Kangrali Industrial Area,
Belgaum-590 010
470302
476951
226822
30139
A)
Registered Office
1.
Shri T.R. Raghunandan
Managing Director
3410340
2.
Shri R. Ramesh Rao
Chief Deivisional Manager
3411112
3410951
3.
Shri K.C. Mallikarjunappa
Dy. General Manager (F&A)
3410180
3338450
Shri K.N. Narasimha Murthy
Company Secretary &
Asst. General Manager (A&P)
3411196
6621794
10. Shri M.F. Talwar
Unit Head, KSACP Limited,
Energy Food Unit, Holalkere Road,
Chitradurga
91423043
11. Shri M.K. Jayaram
Unit Head, KSACP Limited
Weaning Food Unit, P.B. No. 48,
Hyderabad Road, Industrial Area,
Raichur-548 102
35074
3331017
12. Shri Hulluraiah
Unit Head, KSACP Limited,
Weaning Food Unit, No. 126,
Belagola Industrial Area, KRS Road,
Mysore-570 016.
582922
4.
B)
Maize Milling Plant:
5.
Shri V.R. Somavanshi
Dy. General Manager (Mill)
3410180
C)
Feed Milling Plant:
6.
Shri G. Alexandar
Manager (VS)
3410314
D)
Instant Mixing Plant:
7)
Shri Abdul Rasheed
JT. Manager (QC & RD)
3410281
301168
Store the weaning food in rooms free from insects and rats. The rooms
where the material is stored maybe swept clean. If possible also give a
spray of 2% malathion on the walls after emptying the room at intervals
of 2 months. The doors and shutters shall be made tight fitting and without
any crevices and holes to prevent entry of rats. Store weaning food away
from other insects, infected materials and non-food items.
In the absence of suitable storage rooms, commercially available metallic
storage bin of required capacity may be used which will afford protection
against moisture, insects and rats.
Do not open the packets till the time of actual use. If the left over material
is to be preserved for a short time use a clean tin container with tight
fittings lid for storage. Do not use food from opened or damaged packets
which.have been exposed to unclean environment.
with required Vitamins and Minerals. The standard specification for Paustik
Atta/Soya Fortified Wheat Rave/Dhalia is as follows:
SI.
No.
Requirements
Characteristics
1.
Moisture.% by Marx Max
2.
Total Protein (nx6.25) (on dry basis) by mass. Min.
3.
Crude Fiber (on dry basis)% by mass. max.
4.
Calcium. mg/IOOg. Min.
13.00
10-12.50
2.50
120.00
5.
Iron, mg/IOOg. Min.
5.00
Manufacturing units:
6.
Thiamine (as hydrochloride) 100g. Min.
0.25
This food is manufactured at our factories located at Mysore, Belgaum,
Chitradurga, Raichur and Doddaballapur. Each unit produces 12-15
metric tones of Weaning Food every day.
7.
Riboflavin. mg/IOOg. Min.
0.50
8.
Niacin. mg/IOOg, Min.
Also added iodine + Iron enriched salt
2.50
Diversification of new projects :
Due to success and large scale acceptability of Energy Food, the
Company is now engaged in modernisation of Energy food plants as well
as diversifying to take up new production lines for producing low cost
high nutritive. Ready to eat foods like extruded snacks and malted
Weaning Food for the most vulnerable segments of society, like pregnant
mothers and children covered under ICDS/SNP Programme of
Government. Due to introduction of Centrally Sponsored Mid-Day Meal
Scheme and Reformulated Akshya Ahara Programme, the division is
planning Modernisation, Diversification and Expansion Programme to
increase production capacity for supply of Nutritious Food to improve
nutritional status and school attendance of Primary School Children.
Soya Fortified Wheat Soji/Atta/Dhalia:
CH Hl Formula of Paustik Atta is followed for production and supply
of Soya Fortified Wheat Atta/Rava/Dhalia
The wheat Soji/Dhalia/Atta is produced in the most sophisticated Maize
Milling Plant using latest technique of dry Milling Plant at Bangalore is
further sent to Energy Food units for fortification with minerals and is
finally packed properly for dispatching to AEOs/CDPOs.This product is
foilified with Edible Grade Toasted De-fatted Soya Flour. It is further fortified
Semi-processed composite Energy Food Mix, which is specially prepared
in most modem plant of Karnataka State Agro Corn Products Limited,
Fortified with Macro & Micro Nutrient for Nutrition Intervention Programme
of Government. This product is therefore, more nutritious and reliable
than ordinary Atta/Rave/Dhalia available in the Market.This can be utilised
to prepare tasty food preparation akin to local taste by adding available
required spice, oil, seasoning and vegetables for savory preparation and
Jagger/Sugar for sweet preparation.
NEW PROJECT
The Company has conceived a new project for production of Instant Upma
Mix/ Kesari Bath Mix under technical consultancy services of Central
Food Technological Research Institute, Mysore. These are the traditional
food items and are developed as Instant Food Mixes for convenience to
House wives and easy preparation at site in Nutrition Programme. Instant
Upma Mix / Kesari Bath Mix are being commercially marketed under
popular brand name of "SARAL". Most automatic and continuous plant
designed by Central Food Technological Research Institute, Mysore, is
established at Bangalore Complex of the Company. The Instant Upma
Mix / Kesari Bath mix is prepared under most hygienic and sanitary
AGRO FEEDS DIVISION
5.
Broiler Starter: Feed for Broiler birds from 0-4 weeks,
Nearly 30 percent of the Maize Products produced in the Maize Milling
Plant are for use in Livestock Feeds. In order to make efficient use of
these maize products, viz. Poultry Grits, Animal Meal, Maize Germ, De
oiled Cake and Maize Bran, the company took up manufacturing of
Livestock Feeds in the year 1976. The Feeds manufactured by this
company are sold under the brand name “AGROFEEDS”.
6.
Broiler Finisher: Feed for Broiler birds from 5-8 weeks.
7.
Special Layer Mash : Feed to birds to increase production during
laying slumps due to sudden weather changes or disease.
(B)
Cattle Feed:
•
Agro feeds are available in a wide range for Cattle, Poultry, Laboratory
Animals and Fish.
Agro Bye Pass Protein (Pellets): Concentrated feed for high yielding
cows.
•
Agro feeds are made of carefully selected, high quality ingredients
milled and mixed judiciously.
Agro High Fat Ration : Cattle Feed for high milk yielders ranging from
151ts. and above.
•
Agro feed are well balanced, highly nutritious complex mixtures
fortified with all known essential micro nutrients and vitamins at
recommended levels.
Agro Special Milk Ration : For all types of cattle, especially cows
producing 10 to 15 liters of milk per day. Very economically priced. Agro
Milk Ration: Feeds for animals producing 10 Liters and below, dry animals,
etc.
•
Agro feeds help boost production of Milk, Meat and Eggs to maximum
genetic potential.
Agro Calf Meal: Special feed for calves and young ones.
•
Agro Feeds are manufactured under expert guidance and
supervison. Both raw materials and finished products pass rapid
quality controls.
•
Feeds make up about 60% of the cost of production. Feed cost can
be reduced by increased production per unit. Well balanced quality
feeds should be used in animal farming to make reasonable profit.
Feeding good feed to poor stock or feeding good stock poorly is
bound to be unprofitable. This is because heredity sets the upper
limit of the capacity of the livestock to grow, convert feed into milk,
meat and eggs. Feed can do its best only when all other factors are
favorable.
(C) Special Agro Feeds :
1. Maharaja Broiler Starter/Finisher: This feed is highly nutritious
and recommended for Broilers for improved feed conversion in less
number of days.
2. Chick Concentrate : Feed which comprises of Macro Nutrients
and Micro Nutrients like vitamins and minerals. Cereal grains and
byproducts are to be mixed before feeding to chicks.
3. Layer Concentrate : To be fed to layers after mixing required macro
nutrients. Contains adequate level of vitamins.
(A)
Poultry Feeds
(D)
Agro Laboratory Animal Feeds :
1.
ChickMash : Feed for chicks from day old to 8 weeks. This contains
necessary vitamins & supplements required for birds of that age.
1.
2.
Grower Mash : Feed for Growers between the age 8 to 20 weeks.
Agro Rabbit Feed : To be fed to all types of rabbits from the 2nd
week upto slaughter. Contains all nutrients required for a healthy
rabbit.
3.
Layer Mash : Feed required for laying hens from the onset of lay
upto the end of lay 20 weeks to 72 to 80 weeks.
2.
Agro Rat/Mice Feed : To be fed to rat and mice and contains all
nutrients required for healthy growth and breeding.
4.
Breeder Mash : This has to be fed to parent stock.
3.
Agro Guinea Pig Feed : This feed is to be fed to guinea Pigs and
contains all nutrients especially Vitamin C.
Sector
Brief
India
The World Bank Group and Nutrition in India
he World Bank Group
Bengal. In 1992-93, it was esti
has supported nutri
mated that slightly more than half
tion efforts in India
of children under 4 years old are
through two Tamil
undernourished according to
Nadu Integrated
weight and height for age. The
Nutrition projects. In conjunction
'’consequence of such malnutrition
with these projects, the Bank
is lowered potential for physical
Group has helped India better
and mental development and
target nutrition programs, improvei greater susceptibility to disease.
family'nutrition and health
practices, and improve maternal
The Bank's main objective in
and child health services.
assisting the Government of India
in nutrition is to help the central
Through two Integrated Child
and selected state governments
Development Services (ICDS)
adopt policies, strategies, and costprojects, the Bank Group has
effective programs to deal with the
helped the government's ICDS
nutrition problems of pre-school
program address malnutrition,
children (particularly those under
health, and pre-school education
3 years old) and pregnant and
among India's poorest children
nursing women.
and pregnant and nursing women.
And, the Bank Group has worked
In the future, the principal challenge
closely with UNICEF to help
will continue to be developing and
address specific micronutrient
putting in place an effective, effi
deficiencies through the recently
cient, anclsustainable approach to
completed Child Survival and Safe
reducing malnutrition and fostering
Motherhood Project. Today, India
early childhood development.
accounts for the largest.volume of
Bank Group lendirrg'devoted
Completed World Bankspecifically to nutrition programs.
Assisted Nutrition Operations
Despite India's substantial
progress in raising the nutritional
status of its people, the challenge
of malnutrition will be with India
for many years to come. Malnutri
tion consists of deficiencies in both
proteins and micronutrients; in
India, it is highest among sched
uled castes and scheduled tribes.
According to India's National
Family Health Survey (1992-93),
the proportion of children under 4
years old with moderate and
severe malnutrition was close to 60
percent in a number of states,
including Bihar, Uttar Pradesh,
Madhya Pradesh, and West
An IDA credit of US$32 million for
the first Tamil Nadu Integrated
Nutrition Project (TINP) was
approved in 1980 and the project
was successfully completed in 1989.
Its overall goal was to improve the
nutritional and health status of pre
school children, primarily those 636 months old, and pregnant and
nursing women. The project
provided a package of services:
nutrition education, primary health
care, supplementary on-site feeding
of children who were severely
malnourished or whose growth
was faltering, education for diar
rhea management, administration
of vitamin A, periodic deworming,
and supplementary feeding of a
limited number of women.
This project marked the first largescale use of growth monitoring in
India, through monthly weighing
of all children 6-36 months old, to
target delivery of these nutrition
and health services to needy
children, and to educate mothers.
Under this project, some 9,000
community nutrition centers and
2,000 new health sub-centers in 173
of Tamil Nadu's 373 rural blocks
were established. Local participa- \
tion in the project and project
j
coverage were high, and an effec
tive program of mass and interper
sonal communications, particularly
at the village level, was established.
The project cut severe malnutrition
in half and prevented many at-risk
children from becoming malnour
ished. The key to TINP's success
was the great care taken in plan
ning and executing process
<
elements, including careful selec- /
tion and training of community / ,
nutrition workers, heavy emphasis^
on intensive and supportive
supervision, and efforts to gain
community support. TINP today
provides perhaps the largest
longitudinal data base on child
growth and health in the develop
ing world, and lessons learned
from this project were incorpo
rated into the design of TINP II.
Ongoing World BankAssisted Nutrition
Operations
The Tamil Nadu Nutrition II
(TINP II) Project extends the
successful Tamil Nadu pioneer
project from the original 9,000
*^03
villages to most of the state's
20,000 villages. An IDA credit of
US$95.8 million was approved in
1990 in support of this project; the
credit amount has since been
revised to US$67.5 million.
The project aims to:
♦/increase the range, coverage, and
quality of nutrition and health
services:
/♦ improve child feeding and care
practices:
♦ promote community involvement.
/ including support for formation of
women's groups and community
education; and
♦ upgrade project management and
/ evaluation.
India
supports India's ongoing ICDS
Program in the states of Bihar and
Madhya Pradesh. The project seeks
to meet the needs of India's
poorest people, many of whom are
tribal, by improving the nutrition,
health, and pre-school education
status of children under 6 years
old (with special emphasis on
children 0-3 years old), and the
nutrition and health status of
pregnant and nursing women.
Research and Analysis
More than 5 million children under
6 years old and 2 million pregnant
and nursing women benefit
directly from the project's services.
Rebeca Robboy
The Integrated Child Develop
ment Services (ICDS) Project,
approved in 1991, is financed with
an IDA credit of US$74.3 millionrevised from US$96 million. The
project supports India's ongoing
ICDS Program and focuses on
improving the nutrition, health,
and pre-school education status of
tribal, drought-prone, and other
wise disadvantaged people in
Andhra Pradesh and Orissa.
About 5 million pre-school chil
dren and about 3 million pregnant
and nursing women directly
benefit from the project's nutrition
and health services. The project
has succeeded in increasing the
emphasis on reaching pregnant
women and children under 3 years
old, especially in Andhra Pradesh.
An IDA credit of US$194 million
for the ICDS II Project was
approved in 1993. This project
would include efforts to enhance
women's development and their
ability to address issues of malnu
trition at the household level.
Finally, the project would
strengthen the capacity at central,
state, and block levels to provide
high-quality support and training
to functionaries of India's ICDS
program. It is expected that five
states will participate in the
project. The project approach
would vary substantially among
states, depending on their needs,
the status of their existing pro
grams, and their preferences.
Future Operations
ing nutritional issues. The study
A new project, Woman and Child
Development, is now being
prepared which aims to help the
Indian government develop a
more effective, efficient, and
sustainable approach to reducing
malnutrition and fostering early
childhood development. The
project seeks to:
♦
♦
Several analytical studies provide
the basis for the Bank Group's
involvement in nutrition in India.
Among the most important is
Improving Nutrition in India
(1990), which identifies the priority
target populations and geographi
cal areas for nutrition interven
tions, analyzes effectiveness of
various responses to the nutrition
problem, and discusses outstand
improve the health, nutrition,
and psychosocial status of
children 0-6 years old, with
particular emphasis on
preventing malnutrition in
those under 3 years old; and
improve the health and
nutrition of women, particu
larly pregnant and nursing
mothers.
In addition, the project seeks to
improve child care practices and
concludes that:
♦
♦
♦
There are wide variations in
malnutrition across regions,
age, and social groups, and by
gender;
Direct nutrition expenditures
have been modest and not
always sensitive to variations
in malnutrition; and
There is scope to improve the
productivity of expenditures
by strengthening and reorient
ing existing programs and by
reducing mismatches between
expenditures and distribution
of need.
Overall, the study argues for the
need to strike a proper balance
among needs, potential demand,
and available resources.
For more information, please contact:
In Washington:
Rebeca Robboy: (1-202) 473-0669
e-mail: Rrobboy@worldbank.org
In New Delhi:
Geetanjali Chopra: (91-11)461-7241
e-mail: Gchopra@worldbank.org
N u"P tf-
Prevention of Micronutrient Deficiencies:
In attempting to make a further contribution to the state-of-the-
Tools for Policymakers
and Public Health Workers (1998)
art in analysing programme performance, USAID asked the
group of individuals to do a systematic examination of the
edited by Christopher P. Howsen, Eileen T. Kennedy
and Abraham Horwitz, Committee on Micronutrient
Deficiencies, Institute of Medicine
included scientists and programme implementers. Their charge
National Academy of Sciences (NAS) to call together an expert
reasons for the success of programmes and at the same time,
identify the constraints that limited successes.
The group
was to review past approaches that had or had not resulted in
success and to identify the elements of success or failure. The
Review by Frances Davidson, USAID
NAS focused on micronutrient malnutrition because it is a topic
that has seized a great deal of attention from many donors and
country governments. This is due in large part to the elimina
Background
Together
with
many
col
tion of micronutrient malnutrition being seen as something
leagues, USAID has a long
‘doable’ and because we hoped that from this beginning, the
standing interest in identifying
way in which to ensure progress in the larger issues of malnutri
and sharing analyses of pro
tion might be encouraged.
grammes it helps implement so
as to extend their impact and
The case studies represent only a fraction of the many success
encourage others to benefit
ful nutrition programs that have been implemented in develop
They were selected as reflecting broad geo
from these experiences - suc
ing countries.
cesses and failures. To a cer
graphical diversity and as illustrative of a variety of community
tain extent this commitment
and technical approaches.
comes out of the recognition
that meaningful evaluations of
Organisation of the Report
nutrition programmes and their
true impact remains a considerable void in our communal devel
The Report is organised into two volumes. The first volume is
opment experience. Answers to the question ‘what does it really
contents of the first, along with the three commissioned back
take to develop, implement and sustain a successful nutrition
ground papers on vitamin A (by Barbara Underwood), iron (by
intervention' remain elusive.
Fernando Viteri) and iodine deficiency (by John Stanbury). The
In 1989, the International Nutrition Planners Forum published,
specific mcironutrient deficiencies - these recommendations are
the Summary and Key Elements.
The second includes the
NAS report does not offer recommendations on how to alleviate
‘Crucial Elements of Successful Community Nutrition Programs'.
already available through the publications of diverse organisa
In this document an attempt was made to develop an analytic
tions, including USAID, WHO, UNICEF and others. Rather, this
framework to identify the crucial issues identified as responsible
report provides a conceptual framework based on past experi
for the success of a few selected programmes. It was thought
ence that will allow funders to tailor programmes to existing
this might be a practical way of promoting better nutrition and
regional/country capabilities and to incorporate within these
avoiding failures. The 1989 publication synthesised the experi
programmes the capacity to address multiple strategies (e.g.,
ence of USAID's efforts to identify the elements that had been
suppiementation/fortification/other food based approaches/pub-
crucial in achieving nutrition programme success. It found that
lic health measures and multiple micronutrient deficiencies).
success required broad participation in the planning and imple
mentation by those who are expected to benefit from the pro
Several global conferences have focused attention on micronu
grammes and those who are to provide the services. It further
trient malnutrition and raised awareness of the problem and the
documented a developing theme at that time of 'partnerships'
tremendous toll they take in human and country development.
between service providers and targeted groups, between gov
Solutions to these micronutrient deficiencies were said to be
ernment and the private sector, between entrepreneurial groups
technologically possible, and substantial financial resources
and volunteer groups, and other partnerships necessary to
have been committed to solving the problem by many govern
establish and, more importantly, sustain successful pro
ments and donors. Less attention has been devoted to under
grammes. Since then other agencies, notably the World Bank,
the Micronutrient Initiative, and IVACG have made valuable
standing the key elements needed to implement and sustain a
contributions to this discussion.
or national - as opposed to a pilot project scale, at either the
micronutrient intervention on a fully operational scale - regional
national or community level. In fact this has been cited as a
65
kJEcjEUO. 16, dUC y
problem not only of micronutrient interventions but nutrition
programmes in general.
This report focuses on lessons learned from past interventions to
Agriculture, Food and Nutrition for Africa
A Resource Book for Teachers
of Agriculture (FAO, 1997)
address iron, vitamin A and iodine malnutrition - the committee
limited its evaluation to these three micronutrients because it felt
The need for a comprehensive
there was adequate experience for each. However, they believe
source of training materials
that the lessons learned for improving future intervention strate
about African food systems has
gies would also be applicable to prevention and control of
long been recognised. To ad
malnutrition created by deficiencies of other nutrients. And as
dress this need, FAO has pub
the literature and experience accumulate, it will be appropriate to
lished 'Agriculture, Food and
explore similar theses regarding other micronutrients such as
Nutrition for Africa', which is de
zinc, folate and vitamin B12.
signed as a source of teaching
material for teachers of agricul
Early on in the process, it was recognised by the Expert Commit
ture in Sub-Saharan Africa who
tee that there would be an array of potential alternative strate
wish to introduce a food and
gies to deal with micronutrient malnutrition, and that it was
unlikely that any one intervention by itself would solve all the
micronutrient deficiencies in a given region, country or popula
tion group. Thus, the mix of scientists and project implementers
invited to the workshop were designed to help ensure identifica
tion of the optimal combination of interventions most likely to be
successful in a selected context The range of participants also
allowed for complementarities in treating micronutrient deficien
cies to be identified.
tables and figures, has been selected from a range of mainly
English-speaking African countries and ecological regions. The
material is elaborated in nine chapters covering such topics as
the food chain and links among agriculture, nutrition and food
security, food supply systems in Africa, food and dietary diversi
fication, food storage and processing, nutrients and diets, mal
nutrition and micronutrient deficiencies, and nutrition education.
An important feature of this report is the Committee's attempt to
provide a framework for planning intervention programmes that
integrate the three micronutrients and provide matrices for as
signing priorities to interventions in different contexts.
nutrition component into their
training programmes. Resource material, presented in boxes,
The
Committee offers these matrices as guidelines only, recognising
that there may be circumstances in which unique opportunities
or barriers - in both human and material resources - exist that
may lead countries to deviate from the priorities in the matrix. It
is hoped that the matrices offer a useful starting point for
planners and donor agencies.
A special note of thanks is due to the members of the Expert
Committee and the Report Editors who so generously gave of
their time and talents to this endeavour.
Published by the National Academy Press. 224pp (including 51 pp for
the Summary and Key Elements). US $30. Special discount price of US
S24 if ordered through the web (http://www.nap.edu/bookstore). Dis
counts are also available for orders of multiple copies. Both volumes of
the report are available from the National Academy of Sciences Press,
2101 Constitution Avenue, N.W., Lockbox 285, Washington, D.C.
20055, USA. Tel: 1 202 334 3313 Fax: 1 202 334 2451.
Frances Davidson can be contacted at USAID, Office of Health and
Nutrition, RRB, 3rd Floor, 320 21st Street N.W., Washington DC 205233708, USA. Tel: 1 202 712 0982 Fax: 1 202 216 3174 Email:
fdavidson@usaid.gov
With selection and adaptation of the material to meet specific
needs, this resource book may be used for diploma and bache
lor's degree-level courses in fields such as general agriculture,
agricultural extension and agricultural education; for in-service
training courses, workshops and seminars for agricultural ex
tension agents, rural development workers, administrators of
agriculture and of rural development programmes, and govern
ment policy-makers in food, nutrition and agriculture; and for
in-service education of secondary school, college and university
teachers of agriculture.
Published by FAO. 412pp. US $40 (discounts available for developing
countries and bulk orders). Copies are available from the Sales and
Marketing Group, Food and Agriculture Organization, Viale delle
Terme de Caracalla, 00100 Rome, Italy. Tel: 39 6 5705 5727 Fax: 39
6 5705 3152 Email: Publications-sales@fao.org Web: http://
www.fao.org/CATALOG/interact/order-e.html For more information
about this, and other FAO nutrition publications, please email Nutrition
@fao.org
Breaking the Rules,
Stretching the Rules (1998)
A worldwide report on violations of the
WHO/UNICEF International Code of Marketing of
Breastmilk Substitutes
WHO Nutrition Publications - 1998 Catalogue
The 1998 catelogue listing WHO nutrition publications and documents
is now available from WHO Distribution and Sales, CH-1211 Geneva
27, Switzerland. Tel: 41 22 791 2476 Fax: 41 22 791 4857 Email:
publications@who.ch
66
Breaking the Rules, Stretching the Rules 1998 reports on
violations of the WHO/UNICEF International Code of Marketing
of Breastmilk Substitutes' and relevant WHA Resolutions re
vealed during a 31-country survey carried out between January
PUBLICATIONS
and September 1997.
Even
techniques and their effects, and clear suggestions for drafting
though the marketing practices of
protective provisions.
the main producers of infant for
collection of related documents under one cover: the full Inter
mula and other breastmilk substi
national Code, all subsequent relevant WHA resolutions, the
The book also presents a complete
tutes claim to abide by the WHO/
Innocenti Declaration and full text of a dozen baby food market
UNICEF International Code of
ing laws from all over the world. The comprehensive coverage
Marketing of Breastmilk Substi
of the history of the Code, the history of baby milk marketing
tutes, the report provides evi
and of the purpose and achievements of the Code, makes this
dence that the producers con
book valuable reading, not only for lawyers but for everyone
tinue to undermine breastfeeding
who wants to study the legal aspects of the breastfeeding
and infant health.
campaign.
The major conclusion of the report is that the industry continues
to focus on the health care system, building up mailing lists of
new mothers. Most companies have stopped advertising infant
formula directly to the public. Nearly half of the 56-page illus
trated report is devoted to examples of continued violations of
the International Code in hospitals and clinics.
361pp. US$130 for profit organisations; US$50 for non-profit organisa
tions (incl. of surface mail delivery). Published by the International
Code Documentation Centre, International Baby Food Action Network,
Penang, Malaysia. Available from IBFAN, Penang: IBFAN, P.O.Box
19,10700 Penang, Malaysia. Tel: 60 4 6569799 Fax: 60 4 6577291
Email: ibfanpg@tm.net.my
It also gives
numerous examples of companies breaking the rules of the
Source: forward to the 'Code Handbook by Ellen J. Sokol, 1997.
Code and WHA resolutions, by donating samples and supplies,
posters, calendars, promotional booklets and gifts to health
professionals and to mothers.
The subtitle 'Stretching the Rules' refers to the final section of
the report, which describes how new products and practices
have been introduced to a number of countries.
One such
product, marketed by at least 10 major companies, is a ‘formula
for mothers', which, says the report, allows companies to ride on
the breastfeeding wave, sell a new product, and by promoting it
widely, remind mothers, doctors and midwives of their company
name.
The International Code of Marketing of
Breast-milk Substitutes (1998)
A summary of action taken by WHO Member States
and other interested parties, 1994-1998
Since the adoption of the International Code of Marketing of
Breast-milk Substitutes in 1981, and consistent with its Article
11.7, the Director-General of WHO has reported every two
years on the status of the Code's implementation. Thus far 158
of WHO's 191 Member States - 83% in all - have reported to
IBFAN. 56pp. US$6 to non-profit groups; US$15 to profit groups,
inclusive of airmail postage. Copies of the report are available from
IBFAN, Penang: IBFAN, P.O.Box 19,10700 Penang, Malaysia. Tel: 60
4 6569799 Fax: 60 4 6577291 Email: ibfanpg@tm.net.my The report
is also available in French and Spanish.
Sources: IBFAN press release ‘Baby Food Marketing: More Infants at
Risk' 14 March 1998, the report ‘Breaking the Rules, Stretching the
Rules, 1998'.
WHO on action taken in this connection. Primary emphasis has,
been on relevant action taken by Member States, but informa
tion has also been included on WHO's technical support to
governments and action by NGOs, professional groups, and
consumer organisations, which are called upon to collaborate
with governments in monitoring the Code's application (Article
11.4).
This document provides a detailed summary of available infor
The Code Handbook (1997)
by Ellen J. Sokol
mation on action taken by 63 WHO Member States, technical
support provided by WHO, and the activities of a number of
NGOs, especially affiliates of the International Baby Food Ac
tion Network (IBFAN). It complements information provided in
The Code Handbook provides a guide to implementing the
International Code of Marketing of Breastmilk Substitutes'. Each
recent reports by the Director-General on infant and young child
article of the Code is carefully analysed and examples are given
in January 1996 and January 1998, and the Forty-ninth and
nutrition presented to the WHO Executive Board at its sessions
of how different countries have avoided particular weaknesses
Fifty-first World Health Assemblies in May 1996 and May 1998,
and loopholes.
respectively.
It provides a mix of examples of marketing
' The WHO/UNICEF International Code of Marketing of Breastmilk Substitutes was adopted in May 1981 by the World Health Assembly. It presents a
code, developed jointly by WHO and UNICEF, for the marketing of breastmilk substitutes. The code applies to the marketing of breastmilk substitutes,
including infant formula, and other milk products, foods, and beverages, including bottle-fed complementary foods, when marketed or otherwise
represented to be suitable for use as a partial or total replacement of breastmilk. The code deals in successive articles with information and education
needs concerning the feeding of infants, advertising or other forms of promotion to the general public, and standards for product labelling and quality.
35pp. CHF3 (US $2.70); CHF2.10 in developing countries. Available from WHO, Distribution and Sales, CH-1211 Geneva 27, Switzerland. Tel: 41 22
791 2476 Fax: 41 22 791 4857 Email: publications@who.ch Web: http.7/www.who.ch/pll/dsa/index.html The Code is also available in full text on the
IBFAN website at http://www.gn.apc.org/ibfan/fullcode.html (Source: WHO publications website http://www.who.ch/pll/dsa/index.html)
6?
ZdKj UGcjS /JO.16, JULY 199?
The report concludes that since 1981, Member States have
food assistance and purchase, food insecurity and hunger,
gained considerable practical experience, and have provided a
infant feeding, dietary intake patterns, child anthropometry,
wealth of information on the implementation and monitoring of
child and child caretaker health, biochemical assessment and
the Code.
Action taken during the period 1994-8 provides
conclusions and recommendations. A summary is given at the
convincing evidence that many governments are taking seriously
end of each chapter, and tables, graphs and photographs are
their commitment to safeguarding the health and nutritional
used frequently, making the report interesting and easy to read.
status of infants and young children.
WHO/NUT/98.11 31pp. Available in English and French from: Pro
gramme of Nutrition, WHO, 20 Avenue Appia, CH-1211 Geneva 27,
Switzerland. Tel: 41 22 791 3325 Fax: 41 22 791 4156 Email:
akrej@who.ch
Connecticut Family Nutrition Program Technical Report #1, Storrs and
Hartford, CT.52pp. Readers from industrialized countries can request
copies of this report by mailing a US$10 cheque/ money order issued
to 'UConn' to Rafael Perez-Escamilla, Assistant Professor and Exten
sion Nutrition Specialist, Department of Nutritional Sciences University
of Connecticut, 3624 Horsebam Rd Ext, Storrs, CT 06269-4017. Tel:
1 8064865073 Fax: 1 860486 3674 Email rperez@canr1.cag.uconn.
edu There is no charge for readers from developing countries.
Community Nutritional Problems
among Latino Children
in Hartford, Connecticut (1997)
by Rafael Perez-Escamilla,
David A. Himmelgreen and Ann Ferris
WHO Global Database on
Child Growth and Malnutrition (1997)
compiled by Mercedes de Onis and Monika Bldssner
This
Hartford, Connecticut, is an im
and nutritional status of children
of health and social problems,
under five, have been collected by
including poor nutrition. This re
WHO since 1986 as part of its
port presents the results of a
efforts to monitor global progress
needs assessment of the food
in combating childhood malnutri
and nutrition situation of the
tion and to identify those groups in
Latino community living in inner
need of priority interventions.
city Hartford, and identifies a
low levels of breastfeeding (over half the women did not
0
breastfeed their children);
poor dietary quality, in particular the very low intake of fresh
0
fruits and vegetables and the frequent intake of high fat
foods;
0
physical inactivity;
0
high obesity rate (one in five children were obese);
0
excess stunting (11 % of children had stunted growth);
0
iron deficiency anaemia (almost one quarter of children had
anaemia);
0
lead poisoning (one in five children had been diagnosed
with lead poisoning at some point).
The
data, which indicate the growth
tinually confronted with an array
education interventions to improve the nutritional habits of Latino
the vast
Growth and Malnutrition.
poverty and residents are con
families. Results show that special attention needs to be paid to:
presents
WHO Global Database on Child
around 45% of children live in
great need for the development of culturally appropriate nutrition
book
amount of data contained in the
poverished American city where
This detailed account of data on child growth and malnutrition as measured by underweight, stunting, wasting and overweight
- is divided into two parts. Part one explains the importance of
global nutritional surveillance and describes the origins and
development of the database. Against this background, subse
quent chapters summarise global, regional, and national situa
tions and trends for key indicators of child growth and nutritional
status.
Numerous tables and selected maps are used to
indicate the country-specific prevalence and geographical distri
bution of underweight, stunting, wasting, and overweight for
boys, girls and the two sexes combined in developing and
developed countries. Countries are classified according to very
high, high, medium and low prevalence for each indicator and
to global and regional trends are estimated over time. While
noting important achievements in overcoming malnutrition
In light of these findings, the report makes a number of recom
among under-fives, the analysis concludes that global progress
mendations including the continuation of food assistance pro
is entirely inadequate to reach the goal, set for the year 2000, of
grammes, monitoring the impact of welfare reform on household
a 50% reduction in 1990 prevalence levels of moderate and
food security, development of culturally sensitive campaigns that
severe malnutrition. Part one concludes with chapters describ
promote breastfeeding, and promotion of healthier, more nutri
ing the methods used in data collection and their standardised
tious diets and higher levels of physical activity.
presentation, and offering guidance in the interpretation of the
The report has ten chapters covering the following areas: project
design, description of the environment and project participants,
6%
statistical tables.
fiUBU CATIONS
pellier, France, from 28-30 November 1995. This report sum
obesity, and associated consequences of obesity, such as
marises the discussions, conclusions and recommendations of
chronic noncommunicable diseases.
the consultation.
health and economic consequences of obesity and their impact
It also examines the
on development, and makes recommendations for developing
The consultation reviewed a state-of-the-art paper on comple
mentary feeding prepared for the consultation by the Program in
comprehensive public health strategies for prevention and man
agement of obesity.
International Nutrition of the University of California at Davis
(USA). On this basis, the group agreed that new, more precise
recommendations regarding the introduction and duration for
feeding complementary foods are needed.
WHO/NUT/NCD/98.1 296pp. For further information please contact
Chizuru Nishida, Nutrition Programme, WHO, 20 Avenue Appia, CH1211, Geneva 27, Switzerland. Tel: 41 22 791 3317 Fax: 41 22 791
0746 Email: nishidac@who.ch
A number of issues were discussed at the consultation including:
0
the energy needed from complementary foods, the basis for
Guidelines for the Use of Iron Supplements
estimating needs, and major factors affecting energy intake
from complementary foods, in particular energy density and
feeding frequency;
0
protein and micronutrient requirements from complemen
to Prevent and Treat
Iron Deficiency Anemia (1998)
by Rebecca Stoltzfus and Michele Dreyfuss
tary foods, and how complementary foods can provide
adequate nutrient density;
Published by the International Nutritional Anemia Consultative
0
issues of food processing and safety;
Group (INACG), the purpose of these guidelines is to provide
0
programmatic interventions to improve complementary
practical, scientifically sound guidance to those responsible for
planning and implementing anaemia control programmes.
feeding.
The main conclusion and recommendation arising from these
While the main focus of these guidelines is on iron supplemen
discussions was that further research and discussions are
tation programmes and parasite control for pregnant women
For example, it was recommended that further re
and children 6-24 months of age, they also acknowledge the
needed.
search be carried out on the bioavailability of micronutrients from
beneficial role that food fortification and dietary diversification
complementary foods, and the effects of food processing proce
can have in controlling anaemia. Guidelines for the treatment
dures on bioavailability of nutrients.
or referral of people with severe anaemia in primary care
settings, and a summary of key steps necessary to develop an
This report (WHO/NUT/96.9) is available from the Programme of Nutri
tion, Family and Reproductive Health, WHO, Geneva. The state-of-the-
iron supplementation programme are also given.
art review, ‘Complementary Feeding of Young Children in Developing
A selected bibliography lists books and documents that provide
Countries: a review of current scientific knowledge' will be published in
August (WHO/NUT/98.1) For further information, please contact Randa
Saadeh, WHO/NUT, 20 Avenue Appia, Ch-1211 Geneva 27, Switzer
cies that provide support or technical assistance for the control
land. Tel: 41 22 791 3315 Fax: 41 22 791 4156 Email: saadehr@who.ch
of iron deficiency anaemia. Some sources for supplements and
more in-depth information on topics related to iron deficiency
anaemia. Appendices list contact details for international agen
other supplies needed to establish programmes are also listed.
Obesity: preventing and managing
the global epidemic (1998)
Report of a WHO Consultation on Obesity
Geneva 2-5 June 1997
These guidelines are available free of charge from the INACG website
at http://ilsi.org/inacg.html Or contact the INACG Secretariat at ILSI
Human Nutrition Institute, 1126 Sixteenth Street, NW, Washington, DC
20036-4810, USA. Tel: 1 202 659 9024 Fax: 1 202 659 3617 Email:
OMNI@dc.ilsi.org
SCN News No. 14 (p47) reported on
the draft version and recommenda
Food Quality and Safety Systems: a training
tions of this report shortly after the
manual on food hygiene and the hazard
WHO Consultation on Obesity in
1997.
The interim version of the
report is now available for limited dis
analysis and critical control point
(HACCP) system (FAO, 1998)
tribution only, but will be widely avail
able (in final version) at the end of
1998 as part of the WHO Technical
Report Series (TRS).
French and
Spanish versions will follow in 1999.
FAO is the one of the specialised UN agencies dealing with
aspects of food quality and safety throughout each of the
stages of food production, storage, transportation, processing,
and marketing. As part of FAO's ongoing work to build the
capacity of food control personnel, a training manual was
The document reviews global prevalence and trends of obesity
recently published which is intended for trainers in food quality
among children and adults, factors contributing to the problem of
and safety assurance at the government and industry levels.
G&J MEcjG/JO.i 6, JULY igrt
This book is a direct result of an Expert Consultation on Hazard
0
Analysis and Critical Control Point (HACCP) Principles in Food
Ad Hoc Working Group developed a core curriculum as a
dense meal;
0
'train-the-trainer' programme. The core curriculum recognises
the importance of basic quality and safety controls which are
a nutrition education programme, which teaches basic
nutrition messages and preparation of a nutritious, calorie-
Control, which was held in 1994. Shortly after this meeting, an
a nutrition revolving loan programme, which provides sup
plementary food through in-kind loans; and
0
included in the Codex General Principles of Food Hygiene and
an endowment and income generating programme, which
gives grants to communities so they can generate income
Good Manufacturing Practices as embodied in the Codex Codes
through projects.
of Practice as a basis for the effective implementation of the
HACCP system. The training programme has been tested in
Interest from other countries to replicate this successful and
Thailand, Brazil, Vietnam and Slovakia.
sustainable programme outside Viet Nam, has resulted in the
production of these 10 training manuals, which describe the
The manual is structured to ensure that essential information is
training of trainers for the PANP.
provided in a standardised, logical and systematic manner while
adhering to effective teaching and learning strategies. It is
composed of three sections: section one pertains to Principles
and Methods of Training, section two to Recommended Interna
tional Code of Practice - General Principles of Food Hygiene,
Available in English (US $50) and Vietnamese (300,000 VND). For
orders and further information regarding these manuals, please contact
Nguyen ThiTuyet Mai. Tel: 84 48 461801 Fax: 84 48 46 1807 Email:
scusvnfo@netnam.org.vn
and section three to the Hazard Analysis and Critical Control
Point (HACCP) System. Each section is divided into specific
training modules.
New Journal in Public Health Nutrition
This format allows the instructor to select
sections and modules according to the levels df knowledge,
experience and specific responsibilities of the students.
This new journal, launched in March 1998 by the Nutrition
Society and the Centre for Agriculture and Biosciences (CAB)
FAO has prepared this manual in an effort to harmonise the
International on behalf of the Nutrition Society, offers a
approach to training in the HACCP system based on the text and
population-based approach to the practical application of re
guidelines of the Codex Alimentarius Commission. It is clear that
search findings in the field of public health nutrition, and in
HACCP systems can only be effective when they are a part of a
cludes high quality reviews of key topics.
broader food quality and safety programme based on the Gen
editorial team include Barrie Margetts (editor-in-chief), from the
eral Principles of Food Hygiene and Good Manufacturing Prac
The international
Institute of Human Nutrition at Southampton General Hospital,
tices. Consequently, these aspects of quality and safety controls
UK; Lenore Kohlmeier, from the department of nutrition and
are incorporated in the training materials.
epidemiology at the University of North Carolina, USA; Frans
Kok, from the Wageningen Agricultural University, the Nether
Published by FAO. 232pp. IISS30. Copies are available from the Sales
and Marketing Group, FAO, Viale delle Tenme de Caracalla, 00100
Rome, Italy. Tel: 39 6 5705 5727 Fax: 39 6 5705 3152 Email:
publications-sales@fao.org For more information about this, and other
FAO nutrition publications, please email nutrition@fao.org
lands; and Michael Nelson, from the University of London, UK.
A further 13 associate editors are drawn from institutes and
universities worldwide.
Topics covered in this new journal
include:
0
Editor's note: WHO, jointly with the Industry Council for Development
nutritional epidemiology - studies relating nutrition to
health or disease risk;
(ICD) has prepared a training manual on HACCP: Principals and
0
nutrition related health promotion;
Practice. A description of this manual will be provided in the next issue
0
evaluation of effectiveness of intervention studies aimed at
ofSCN News (No. 17, December 1998).
improving health;
0
role of nutrition in high risk and vulnerable groups;
0
development of research methods, validation of measures,
Poverty Alleviation and Nutrition
Program Manuals (1997)
Save the Children US-VietNam Field Office
Since the implementation of the Poverty Alleviation and Nutrition
Programme (PANP), over 90% of moderate and severely mal
nourished children participating in the PANP have have re
sponded to nutrition rehabilitation services.
The PANP has four components:
0
a growth monitoring promotion programme, which encour
ages the weighing of children under 3 years old to deter
mine their nutritional status;
?2
calibration;
0
population-based research related to primary prevention of
illness.
Public Health Nutrition will be issued four times per year. The inaugural
issue was published in March 1998. For more information, or to submit
papers or suggest topics of interest for future supplements and special
issues, please contact the Editor-in-Chief, Dr Barrie Margetts, Institute
of Human Nutrition, Southampton General Hospital, Southampton, UK.
Tel: 44 1703 796 530
Fax: 44 1703 796 529
Email:
bmm@soton.ac.uk Information about subscription is available from
CABI, Wallingford, Oxon, 0X10 8DE, UK. Tel: 44 1491 832111 Fax:
44 1491 826090 Email: marketing@cabi.org or visit the website at
http://cabi.org/catalog/joumals/
NUT- If- ■
Public Health Practice
More nutrients, fewer parasites, better learning
Tara Gopaldas
By 1997 it is intended that all of India's 160 million primary
school children will be given a free daily midday meal. Since
1994 almost 3 million such children in Gujarat, already
benefiting from this initiative, have been receiving, in addition,
supplements of iron, iodine and vitamin A, and deworming
treatment with albendazole. As a consequence there have been
significant, highly cost-effective and sustainable improve
ments in growth rates and haemoglobin levels, and decreases
in the prevalence of ocular signs of vitamin A deficiency and in
intestinal parasitic infections.
Children cannot benefit fully from primary
education unless they are in a satisfactory state
of health. It is particularly important that they
should be well nourished and free of diseases
associated with deficiencies of iron, iodine and
vitamin A. Since August 1995, 40 million pri
mary-school children in India have been re
ceiving a free midday meal, and it is intended
that by 1997 all of the country’s 160 million
children in this category will be doing so. In
the State of Gujarat, nearly 3 million primary
school children, already receiving a free mid
day meal, have also been given iron tablets,
vitamin A capsules and iodized salt, in addi
tion to deworming tablets containing albenda
zole. An evaluation of this initiative has been
made by Tara Consultancy Services, a non
governmental organization which works with
Partnership for Child Development, of Oxford
University, UK.
Professor Gopaldas is Director of Tara Consultancy
Services and a member of WHO's Advisory Committee
on Nutrition. Her address is Tara Consultancy Services,
124/B Varthur Road, Nagavarapalaya, Bangalore
560093, India.
World Health Fomm ■ Volume 17 • 1996
Setting up and running the project
Focus group interviews were conducted with
government officials, teaching staff, parents
and schoolchildren before treatment started, in
order to assess opinion on the proposed
courses of action.
■ Midday meal programme officials said that
most children suffered from worm infesta
tion and nutritional deficiencies.
■ Many children said that they passed worms,
felt tired and could not always see pro
perly.
■ Parents were generally unaware of these
problems.
■ All interviewees responded positively to the
intended programme. The teaching staff
and parents said that they would help to
carry out treatment.
The midday meal programme commissioners
procured adequate supplies of albendazole
tablets (400 mg) and iron tablets (60 mg) and
vitamin A capsules (200 000 IU) for almost
3 million primary-school children. Iodized salt
was used routinely in cooked meals.
367
Public Health Practice
Pharmaceutical firms transported the products
to the districts or talukas where the health
officers cooperated in storing them. The offi
cials and organizers of the midday meals pro
gramme collected their quotas and dosed the
children for whom they were responsible as
prescribed by an expert technical committee.
Procurement, delivery and receipt of the pro
ducts were all conducted in a highly efficient
manner.
Highly cost-effective and efficient training
pyramids were established, with the chief dis
trict health officers at the top and the helpers
and cooks at the base. The shelf-life of ±e
products exceeded two years, provided they
were kept in a dry place and, in the case of •
vitamin A, away from the light. In the focus
group interviews, all providers and receivers
exhibited enthusiastic acceptance of the pro
gramme.
Findings and outcome
Nearly 75% of schoolchildren in a slum area
carried infections of Entamoeba histolytica
and/or roundworms, most of them severe to
moderate. Infected children in the age range
of 6-15 years were 2 kg lighter and 3 cm
shorter on average than non-infected children.
The mean haemoglobin levels in infected and
non-infected children were 10.4 g/dl and
11.6 g/dl respectively. Children aged
11-15 years showed a more severe depression
of haemoglobin than did younger children.
Observations were made on 3000 children in
three districts shortly before and a year after
two rounds of dosing. It was found that older
children benefited more than younger ones.
The improvements detected were as follows
among children aged 6-15 years.
■ On average, dosed children were 1.1 kg
heavier and 1.1 cm taller than undosed
children.
■ The prevalence of intestinal parasitic infec
tion fell from 71% to 39%.
■ The prevalence of night blindness and ocu
lar signs of vitamin A deficiency fell from
67% to 34%.
■ Many dosed children said that they felt
more active than previously and that their
eyesight in poor light had improved.
■ Children who had been infected with
worms felt greatly relieved to be rid of
them.
Many studies throughout the world have
shown that, in general, people on low
incomes suffer more from iron and vitamin A
deficiencies than from inadequate calorie or
protein intake, and tend to be comparatively
heavily infected with intestinal parasites that
greatly inhibit growth and depress levels of
iron and vitamin A. Wherever iodine defi
ciency disorders are endemic it is essential that
all people use iodized salt. Even moderate
iodine deficiency can have an adverse
influence on the learning process.
Deworming, and supplementation with iron
and vitamin A, should be organized as parts of
a single strategy. Deworming helps to maintain
haemoglobin levels for three to four months.
Adequate dietary iron is needed for cognition
and physical activity, while vitamin A, as well
as being vital to the eyes, combats common
morbidities, especially upper respirator}' tract
infections. Reducing these complaints also
reduces absenteeism among schoolchildren.
Though the programme may seem ambitious,
its financial requirements are very modest. The
annual cost per child of albendazole, iron,
vitamin A and iodized salt is approximately
USS 0.50; that of midday meals is about $ 20.
Preferably, of course, both the treatments and
the midday meals should be given. ■
■ After one year the mean haemoglobin level
was 12.4 g/dl, whereas before treatment it
had been only 10.6 g/dl.
368
World Health Faun ■ Volume 17 • 1996
TIPS FOR BETTER COOKING OF LEAFY VEGETABLES
COOK LEAFY VEGETABLES CAREFULLY TO
CONSERVE MAXIMUM NUTRIENTS
— Wash leafy vegetables thoroughly before chopping,
particularly when used as salad.
— Use minimum amount of water for cooking.
— Do not throw away the water in which the leafy
vegetables have been cooked. Use it in dais, soups or for
dough, if left.
— Cook leafy vegetables for a short-time.
— Cook them in a covered vessel.
— Avoid deep frying of leafy vegetables.
USE LEAFY VEGETABLES THROUGHOUT THE YEAR BY DEHYDRATING THEM
Leafy vegetables when available in plenty at low-cost can be purchased in bulk. These should be cleaned, washed
and spread on a clean sheet for drying. When completely dried., powder them coarsely by rubbing with hands and
store in air-tight containers. Use when fresh supply is not available
EAT ATLEAST ONE PREPARATION OF LEAFY VEGETABLES EVERYDAY
NUTRITIVE VALUE OF SOME GREEN LEAFY VEGETABLES
(PER 100g. OF EDIBLE PORTION)
SI.
No.
1.
2
3.
4
5*
6.
8.
9.
10
11.
12.
13.
14.
15.
16.
18.
19.
20.
21.
22.
Name
Amaranth tender
Bathua leaves
Beet greens
Bengal gram leaves
Cabbage
Carrot leaves
Cauliflower greens
Celery leaves
Colocasia leaves
Coriander leaves
Curry leaves
Drumstic leaves
Fenugreek leaves
Katha Sag
Knol-Khol greens
Lettuce
Mint
Mustard leaves
Radish leaves
Rape leaves
Spinach
Turnip greens
Iron
mg
3 49
4.2
16.2
23.8
0.8
8.8
40.0
6.3
10.0
1.42
0.93
0.85
1.93
_
13.3
2.4
15.6
16.3
18.0
12.5
1.14
28.4
Calcium
mg
397
150
380
340
39
340
626
230
227
184
830
440
395
253
740
50
200
155
310
370
73
710
Vitamin A
(as Carotenejug)
5,520
1,740
5,862
978
120
5.700
Vitamin C
mg
99
35
70
61
124
79
3.990
10,278
6,918
7,560
6,780
2,340
62
12
135
220
52
4,146
990
1,620
2,622
5,295
1,380
5.580
9,396
157
10
27
33
81
65
28
180
[g Produced by D.A.V.P. for Department of Food, Min. of Food and Civil Supplies, Govt, of India and printed at M/s Rakesh Press, New Delhi.
No. 7/1/89-PP V
English 61,000
March 1990
CONSUME GREEN LEAFY VEGETABLES DAILY
AND IMPROVE
YOUR VITALITY
FOOD AND NUTRITION BOARD
DEPARTMENT OF FOOD
MINISTRY OF FOOD AND CIVIL SUPPLIES
GOVERNMENT OF INDIA
KRISHI BHAVAN
/
NEW DELHI
|
GOOD EYES NEED VITAMIN A
VITAMIN A PREVENTS BLINDNESS
GOOD BLOOD NEEDS IRON
IRON PREVENTS ANAEMIA
GREENS ARE FULL OF VITAMIN A AND IRON
__________________ GREEN LEAFY VEGETABLES ARE HIGHLY NUTRITIOUS
Green leafy vegetables are a store-house of important minerals and vitamins and are, therefore, classified as,
protective foods. These are rich sources of Iron, Calcium, Vitamin A (as Carotene), Vitamin C and Vitamins of BComplex Group particularly Riboflavin and Folic Acid. These leafy vegetables also provide some proteins though in
small quantities. The green leafy vegetables when mixed with cereal-pulse combination enhances the quality of
protein of the diet. Leafy vegetables help in building strong bones, healthy teeth and gums.
GREEN LEAFY VEGETABLES ARE GOOD FOR EYES
Vitamin A is a nutrient which is specially important for the health of the eyes in small children. In the absence of
adeuate amounts of Vitamin A in the body, the eye balls lose their usual moist white appearance and become dry and
wrinkled. There is inability to see in dim light (Night blindness). This is the early stage of Vitamin A deficiency and if not
treated in time, the eyes may become absolutely red and the cornea (black portion of the eye) may finally burst leading
to permanent blindness.
Though Vitamin A as such is present only in foods of animal origin like butter, ghee, whole milk, curd, egg yolk and
liver. Nature has provided a safeguard by giving us green leafy vegetables which contain a substance known as
"Carotene". This Carotene when consumed gets converted into Vitamin A in our body and helps protect our eyes.
Green leafy vegetables by virtue of having large amounts of Carotene in then? not only protect our eyes but also
promote physical growth in children and help in building up resistance to diseases.
GREEN LEAFY VEGETABLES ARE GOOD FOR BLOOD
Our body needs nutrients like Iron, Folic Acid, Vitamin B12, Protein and Vitamin C to make our blood healthy. If we
do not get enough of these nutrients in our food, specially Iron, we may suffer from Anaemia, a condition in which the
red pigment of the blood known as haemoglobin gets reduced. Anaemia can affect any age-group but is more widely
prevalent among women of child bearing age and children. Anaemia reduces the working capacity of the person and
may also lead to pre-mature deliveries, low-birth weight babies, maternal deaths and many other abnormalities. Early
tiresomeness, loss of appetite, breathlessness on slight exertion, giddiness, palor of skin particularly inside the lower
eyelids, fee, tongue, lips and nailbeds are some of the common signs of anaemia.
Green leafy vegetables are rich sources of Iron and consumption of about 50 gms. of such vegetables in the daily
diet can take care of body's iron requirements considerably. Vitamin C present in green leafy vegetables helps to
absorb iron more efficiently.
DO YOU KNOW THAT THE CONTENT OF VITAMIN A (AS CAROTENE) AND IRON IN GREEN LEAFY
VEGETABLES IS MUCH MORE THAN THOSE IN MANY OF THE COSTLY FRUITS AND VEGETABLES!
GREEN LEAFY VEGETABLES ARE A GOOD SOURCE OF DIETARY FIBRE
The fibre content (roughage) of the diet has many health generating properties. The roughage supplied by leafy
vegetables is also useful for good digestion.
GREEN LEAFY VEGETABLES ARE CHEAP
The green leafy vegetables which are essential for growth and maintenance of normal health are in-expensive
source of many nutrients. They can be easily grown in the kitchen gardens.
INCORPORATE LEAFY VEGETABLES IN YOUR DAILY DIET
Spinach, Amarnath, Fenugreek Leaves, Drumstick
Leaves, Radish Leaves etc. are generally consumed all over
the country. Usefulness of these leafy vegetables are to be
realised and these should be included as an essential
component of our daily diet. Besides the traditional dishes
which are prepared using green leafy vegetables, the
following prepartions can also contain green leafy vege
tables and can be used in our daily diet
— Mixing cut leafy vegetable with cereal flour for making
chapatis, missi roti, paranthas etc.,
— cooking leafy vegetable with a little amount of water for
a short-while and making the dough for puris with this,
— adding leafy vegetable to preparations like khicheri and
uppuma,
— preparing dal with leafy vegetable.
— preparing leafy vegetable with bengalgram flour,
— preparing mixed vegetables including leafy vegetables,
— preparing bhujias from leafy tops of carrot, radish, turnip, beetroot, etc. and other leafy vegetables,
— preparing raitas with leafy vegetables,
■
— preparing chutneys with leafy vegetables and incorporating coconut or groundnut.
Subject:
Date: Mon, 29 Jul 2002 11:24:30 +0000
From: "umesh kapil" <kapilumesh@hotmail.com>
To: abdey@hotmail.com , ninoo@mantraonlme.com, anoopmisra@hotmail.com,
sdeorari@yahoo.com, dwivedi7@holmail.com, skkabra@holmail.com,
crhspaiims@sancharnet.in, nkmanan@hotmail.com, cspandav@mantraonline.com,
itisprccti@hotmail.com, priyalipathak@hotmail.com, rajiv.bahl@cih.uib.no,
renusax@hotmail.com, skant76@hotmail.com, shiniini_bhatnagar@rediftinail.com,
suneeta_mittal@yahoo.com , vkalra@mantramail.com, vinodkpaul@hotmail.com,
ykg@hotmail.com, anika_hk@yahoo.com, sawasthi@sanchamet.in, kbagchi@del3.vsnl.net.in,
dsack@icddrb.org, skroy@icddrb.org, loretta@icddrb.org, sochara@vsnl.com,
pjf@mrc.soton.ac.uk, pvkotecha@yahoo.co.uk, sanjivskbhasin@rediffmail.com,
deepika@pca-intl.com, dchaudhery@careindia.org, lparker@careindia.org, rdevi@careindia.org,
tkiran@careindia.org, director@cftri.com, prakash@cftri.com, jampr55@hotmail.com,
jaml23@eth.net, cini@vsnl.com, cini@cal.vsnl.net.in, crsoman@vsnl.com, swarup@dbt.nic.in
IX ASIAN CONGRESS OF NUTRITION
^BRUARY 23rd - 27th, 2003, NEW DELHI,
INDIA
Secretariat:- Nutrition Foundation Of India
C-13, Qutab Institutional Area, New Delhi-110016,
Tel:-91-11-6962615; Tel fax:- 91-11-6857814
India.
website: www.acn2003india.net
Dear Colleague,
As you may be aware that the IX Asian Congress of Nutrition is to be held
in New Delhi, India between February 23-27, 2003. The Second Announcement of
the Congress containing the details of Scientific Programme, Registration,
Accommodation and Abstract submission can be downloaded from the website:www.acn2003india.net
With warm regards
C. Gopalan
President
Chat with friends online, try MSN Messenger: http://messenger■men■com
PSUS TEMPLES OF DOOM |
FOOD CORPORATION OF INDIA
WASTrSIDE STORY
incorporated: 1965; Headquarters: Delhi; Business: Procurement, storage and distribution
of foodgrain; Number of workers: 2,08,0110; Annual wage bill: Rs 875 crore
■ By Malini GOYAL
F5(
TS}
I®
OSS, INEFFICIENCY. CORRUP
tion. waste, damage... Huntfor
synonyms of ineptitude. Of all
•',!
.he words you find, add one
X^S’imore to the list: fci. or the Food
;■■■ .ration of India. Manned by a
work force of almost two lakh
(including contract labourers) and
with 11 ias officers at the top. the fci is
not just a temple of doom. It is an
institution of inefficiency.
if that sounds harsh, check the
facts, fci godowns are overflowing
with 45.5 million tonnes of food
grains (wheat and rice) right now.
That's 3 5 per cent of the total rice and
wheat India produced last year and al
most three times the buffer stock the
government is supposed to maintain.
A rough estimate of the cost of hold
ing the excess grain is Rs 15,000
crore. At least one million tonnes are
believed to be rotten and about two
lakh tonnes are classified as damaged.
So frustrated was the Parliamentary
Committee probing into fci's func
tioning that it recently suggested
dumping some foodgrain into the sea
as a way out.
Waste has become a way of life at
the fci. Foodgrain worth Rs 500 crore
is lost in transit every year. That’s
nothing compared to the Rs 8 7 5 crore
that goes into paying salaries, fci
workers are among the highest paid
in the country, earning an average of
Rs 20.000 a month. But fci Managing
Director J.S. Gill laughs away the wor
ries. In a short, five-minute interview
he told INDIA today that "besides the
wage bill, the other costs are not at all
alarming". Well, how does one put
this diplomatically. Gill is either igno
rant or is being a “good" bureaucrat.
Some more numbers to prove fci's
inefficiencies. In 1998-99 it spent
Rs 808 on every quintal of wheat and
Rs 980 on every quintal of rice it
procured. But it sold that wheat for
Rs 396 a quintal and the rice for Rs
611 a quintal, implying that for every
100 kg of wheat and rice it bought
FOOD MINISTER SHANTA KUMAR ■ “FCI’S role must shrink”
UNION FOOD AND CIVIL SUPPLIES
Minister Shanta Kumar spoke to Special
Correspondent malini coyaloh the ra's role.
On the relevance of FCI: We will need
the fci for food security and toensure that
farmers are not exploited. But the Gov
ernment's role has to be restricted. We
need a balanced approach so that farm
ers are not discouraged.
On Government interference in ra:
Government should regulate and not get
into business. We have seen the problems
that government involvement in busi
ness has created in psus. Now the Gov
ernment is trying to correct past wrongs.
On winding up fci: It has some flaws
but its existence is still very important.
But it needs to be restructured and we
have set up a committee to look into
that. Downsizing of staff is envisaged.
On the future of fci: Our food strat
egy was drawn up in the age of scarcity.
That strategy is now irrelevant.
Full text of interview at www.india-today.com
PRAMOD PUSHKARNA
buy foodgrain from farm
grain and allowing their
ers at low prices and then
free movement across
connive with officials to
the country. Says Hardsell it to the ra at the offi
eep Singh, president.
cial price. This year in
Cargill India: 'A consis
Punjab, while the farmers
tent government policy
sold paddy at Rs 2 50-4 75
is important for the
a quintal, commission
entry of mncs."
agents made a killing by
Once states are given
selling it to ra at Rs 510responsibility of holding
HAT'S exactly what the fci
540 a quintal, ra’s army
their own stocks, politi
was not meant to do when it
of officials also make a
cal pressures to purchase
was set up in 1964. Born in
fortune in the process. So
just any amount of food
the era of food scarcity the
rampant is thecorruption
grain of any quality will
corporation's basic charter
in the ra that a former
lessen. The Central gov
ASHOK GULATI,
was to ensure farmers get a remuner
chairman terms it the
ernment on its part must
professor,
IEG
ative price for their produce, help sta
Food Corruption of India.
not artificially hike the
bilise food prices in the country and
But then the fci has
purchase price for food
feed the Public Distribution System
never been allowed to be a
grain. This will ensure
(pds) which was set up concurrently. It
“corporation", and has
that the ra does not have
was supposed to be a last resort buyer,
been functioning more as
to buy foodgrain at
offering farmers a minimum support
a government depart
prices higher than the
price to save them from exploitation
ment. "The fci has no
open market. The best
by traders. But over the years two fun
control over the price.
way to achieve this is to
damental changes have made a mock
quantity and quality of
follow the purchase price
ery of such noble intentions.
what it buys." points out
recommended
every
Firstly, political interference has
former managing direc
year by the Agriculture
forced fci to purchase foodgrain at a
tor Sarita Das. Those are
Cost and Price Commis
price higher than the market rate and
basic business decisions
sion (ACPC).
in much bigger quantities than are
forany commercial enter
FCt's buying and stor
needed as buffer stocks. "Minimum
prise. On its part, the Gov
ing should be done with
support price has become the maxi
ernment virtually writes
modern
technology.
KIRIT PARIKH,
mum support price and fci has become
off fci’s losses under the
Countries like Israel have
buyer of the first—not last—resort,”
Director, IGIDR
guise of food subsidy.
storage facilities where
says Ashok Gulati, professor at the In
The confusion over
foodgrain can be kept for
stitute of Economic Growth. With the
the fci’s relevance has forced the gov
up to 100 years without any quality
country transiting to an era of food sur
ernment to contemplate its closure
loss. Says Arvind Singhal. managing
plus. the market prices of wheat and
twice in the past—once during the
director of KSA Technopak: "Mecha
rice often fell below the pds prices. That
Janata Party rule in 19 79 and again in
nised handling of grains should be in
cut down the sales through the pds—
the early 1990s. However tempting it
troduced without delay." To his credit.
saddling the fci with swelling stocks.
may sound, an outright closure of fci
Union Food and Civil Supplies Minister
Notwithstanding the glut, from Punjab
is not the solution—at least not right
Shanta Kumar does admit that the Fa
alone, the fci was forced to purchase 11
now. The first step should be to shrink
cannot continue in its present form.
million tonnes of rice this year, much of the fci by restricting its role only to | Says he: “In the changed circum
it sub-standard. This is estimated to
management of buffer stocks. States. I stances. the ra's role needs to be looked
cost fci up to Rs 9.000 crore.
which actually run the pds shops, can i into." (see interview). He has set up a
Ironically, small farmers are not the
be asked to store and maintain food- I committee headed by acpc Chairman
grain stocks. Concurrently, the I Abhijit Sen to examine the Fa's role. Its
ones reaping the benefits of such
largesse. It is the middlemen—known
Government must allow greater , report is expected in three months.
as commission agents—who take away
access to private traders by removing i Now. only if the Government is able to
the thickest slice of the pie. The agents I restrictions on private storage of food- I digest the food for thought it will get. ■
and sold, fci was losing Rs 412 and Rs
369. Multiply that with the 45.5 mil
lion tonnes of wheat and rice stocked
in fci godowns and the enormity of the
loss hits you. “fci’s cost of buying and
procurement is twice as high com
pared to private traders." says Kirit
Parikh, director. Indira Gandhi Insti
tute for Development Research.
T
“Minimum
support price
has become
the maximum
support
price.”
“The procure
ment cost of
FCI is double
compared to
that of private
traders.”
PuT- V
A
11
jt? Report on
The World Nutrition Situation
January
2000
Nutrition
Throughout
the Life Cycle
United
Nations
Administrative
Committee on
Coordination
Sub-Committee on Nutrition (ACC/SCN)
in
collaboration
with
International Food Policy Research Institute (IFPRI)
1
NUTRITION THROUGHOUT
THE LIFE CYCLE
utrition challenges con
N
tinue throughout the life
cycle, as depicted in Fig
ure 1.1. Poor nutrition often starts in utero and ex
tends, particularly for girls and women, well into
adolescent and adult life. It also spans generations.
Undernutrition that occurs during childhood, ado
lescence, and pregnancy has an additive negative im
pact on the birthweight of infants. Low-birthweight
(LBW) infants who have suffered intrauterine
growth retardation (IUGR) as foetuses are born un
dernourished and are at a far higher risk of dying in
the neonatal period or later infancy. If they survive,
they are unlikely to significantly catch up on this lost
growth later and are more likely to-experience a vari
ety of developmental deficits. A low-birthweight in
fant is thus more likely to be underweight or stunted
in early life.
The consequences of being born undernourished
extend into adulthood. Epidemiological evidence from
both developing and industrialized countries now sug
gests a link between foetal undernutrition and increased
risk of various adult chronic diseases—the “foetal ori
gins of disease hypothesis.”1
FIGURE 1.1: Nutrition throughout the life cycle
Source: Prepared by Nina Seres for the ACC/SCN-appointed Commission on the Nutrition Challenges of the 21st Century.
NUTRITION AND HUMAN
DEVELOPMENT
4
ew people—whether or not
F
they are nutrition profes
sionals—would dispute the
fact that malnutrition constrains people’s ability to
fulfill their potential. Hungry and undernourished
people have less energy to undertake work, are less
able to attend school, and once in school are less able
to concentrate and learn. Diet-related chronic dis
eases take highly experienced individuals our of the
work force and take resources away from primary
health services. That improved nutritional status will
lead to an improved ability to secure rewarding and
sustainable livelihoods is a common sense proposition.
How important is malnutrition to economic
growth? Researchers have derived conservative esti
mates of the forgone gross domestic product
(GDP) as a result of iron deficiency alone in child
hood and iron, iodine, and protein-energy malnutri
tion in adults.1 For Pakistan the annual losses are
over 5% of GDP. For Bangladesh, the cost of iron
deficiency in children alone is nearly 2% of GDP.
Nutrition and food securin’ also promote economic
growth by reducing the potential for conflict.2 Chap
ter 5 shows that the resources required for relief ac
tivities are large and growing. Understandably these
activities retain the first call on resources—resources
that could otherwise be allocated to longer-term de
velopment activities. The designers and implement
ed of relief programmes are very aware of the im
portance of building development into relief
activities. In general, the need for future relief flows
can be reduced by improving nutrition today. Re
duced relief flows will increase the availability of
funds for longer-term development. Improvements
in nutrition can thus serve as a crucial spur to overall
economic growth.
If the contributions of nutrition to economic de
velopment are underrated, so too are the reverse contri
butions—both positive and negative. Economic and
demographic events such as globalization, HIV/AIDS,
and urbanization have large and far-reaching impacts
on human development—such as the capability’ to be
well nourished and healthy, to undertake healthy repro
duction, and to be educated and knowledgeable—and
thev must be taken into account in developing nutrition
strategies.
The emergence of human development as a guid
ing principle for overall development reflects a growing
dissatisfaction with an exclusive reliance on economic
growth as a means to development. The focus on hu
man capabilities has opened the door for more norma
tive arguments, including a human rights-based ap
proach to development. In his launch of the United
Nations reform, Secretary General Kofi Annan stated
that all major UN activities should be undertaken
through a human rights perspective. Many UN agen
cies, particularly the UNDP, UNFPA, UNHCR, and
UNICEF, began operationalizing a “human rights
approach” to development. The debate about whether
or not the UN should base its work on human rights
was over. The challenge now is how to develop human
rights-based strategies.
This chapter discusses these themes in more detail.
First, it describes some recent developments that high
light the contributions of improved nutrition to the
overall development process. Recent studies, for exam
ple, confirm the strong relationship between infant nu
trition, cognition, and school enrollment—linkages ex
ploited by the early childhood initiatives of the past five
years. The chapter then considers some of the policy
impbeations of new research on the Enks between foe
tal undernutrition and diet-related chronic diseases in
adults. This section of the chapter closes with a discus
sion of the resurgence of interest in participator}’ de
velopment approaches and the contributions that
community-based nutrition initiatives might make to
overall development.
Second, the chapter describes some major so
cioeconomic and demographic events together with
their implications for nutrition policy and program
ming. The chapter considers the impbeations of the
freer movement of financial resources, food, and
43
January 2000
information (three aspects of globalization) for food
school.’ For Pakistan, an improvement of 0.25 jq
and nutrition policy. The chapter then discusses the
implications of rapid urbanization and of HIV/
Z-score height-for-age will lead, on average, to an in
crease in subsequent school enrollment rates of 2%
for boys and 10% for girls. This increases to 5% and
AIDS for food and nutrition policy. Finally, the
chapter describes the emergence of the human
rights perspective. The ascent of the human rights
agenda in an era of globalization is more than a coin
cidence. Human rights principles will play a crucial
role in the type of globalization that emerges over
the next ten years.
4.1 The Relevance of Nutrition
for Development
Three emerging bodies of work highlight the nature
of the link between nutrition and human develop
ment: (1) nutrition, cognition, and school enroll
ment, (2) foetal nutrition and adult chronic disease,
and (3) the importance of community-based ap
proaches to development and the leadership of the
nutrition communin’ in this regard.
Nutrition, Cognition, and
School Enrollment
Recent studies from the nutrition and economics lit
eratures reaffirm the importance of nutrition for the
cognitive achievement and school enrollment of
children. In addition, study after study demonstrates
that women’s educational attainment is a key factor
in preventing infant undernutrition3 and that overall
educational attainment is the key factor in escaping
poverty.4
Recent nutrition studies confirm the strength of
these relationships. Strong associations are found
between the stunting of Filipino children under age
2 and their cognitive ability test scores between ages
8 and ll.5 There is a strong link between suboptimal neonatal nutrition and cognitive function,
particularly in males.6 In Jamaica stunting was
strongly associated with developmental levels in 1and 2-year-olds.7 Nutritional supplementation and
stimulation of stunted children between 9 and 24
months of age have independent and additive ef
fects on the development of the children at the age
of 7-8 years.8
The economics literature offers compelling evi
dence of the importance of nutrition for develop
ment. At the mean of a nationally representative
sample from Ghana, a 10% increase in stunting
causes a 3.5% increase in age of first enrollment at
44
16%, respectively, when diarrhoea rates are reduced
by half.10 Another recent study yields smaller im
pacts on child schooling performance, but the link is
still statistically significant.11
Given that these findings come from both ex
perimental design and observational data and from
both the nutrition and economics literatures, and
that stringent statistical and econometric techniques
have been used to generate them, they present a
convincing and scientific basis for early childhood
interventions.
Policy Implications of the Link
between Foetal Undernutrition and
Adult Chronic Disease
Evidence on the links between foetal undernutrition
and chronic disease in adulthood has been discussed
in Chapter 1. The implications of these links for for
mulating development policies are only now being
thought through. Three points are noteworthy. First,
an investment in avoiding foetal undernutrition be
comes an even better investment because it not only
improves maternal and infant nutrition but also slows
down or prevents the onset of chronic diseases in
later life. Of course, preventing these effects is intrin
sically valuable, as emphasized by the human rights
approach. In addition, prevention will have a signifi
cant impact on economic productivity—an impact
that has not been captured in conventional estimates
of the economic returns to improved nutrition.
Second, increasing health expenditures—whether
private or public—to modify behaviour and prevent
undernutrition throughout the life cycle may well di
minish or at least postpone health expenditures to
later in life. This postponement will better allow age
ing populations to lead productive adult lives, thus
enabling them to better insure themselves—formally
or informally—against health shocks. Third, if the al
location of public health resources is to be guided by
the global burden of disease metrics such as disabilityadjusted life years lost (DALYs), then the new findings
will lead to an enormous increase in the rationale for
investing in adolescent, maternal, foetal, and infant
nutrition, simply because foetal undernutrition is a
leading cause of such major components of the
global burden of disease as cardiovascular disease,
hypertension, and obesity.
Chapter 4
Nutrition and Human Development
Decentralization and the
Empowerment of Communities
Many institutions throughout the world are rapidly
decentralizing the allocation of public resources—
whether health and nutrition or otherwise. In princi
ple, moving authority and accountability closer to
the intended beneficiaries of an initiative—poor
communities, for example—is likely to strengthen
the incentives to use public funds more effectively
and to facilitate the generation of complementary
private funds. In practice, however, mechanisms to
ensure sufficient local capacity and accountability
have to be present as well. Communities also have
embedded power structures, and in the absence of
transparency and accountability mechanisms, local
groups can misallocate funds. Moreover, if local
communities are to compete for central funds, the
better-equipped, more-cohesive, and less-excluded
communities will capture them. Communities that
are unable to organize proposals or are less likely to
be noticed by central authorities will lose out.
The nutrition community has taken leadership
in this area. Community-based nutrition program
ming has long been considered a vital component
of the fight against malnutrition.12 Can these
community-based efforts serve as a way of empower
ing communities to participate in other development
activities? The body of quantitative empirical research
on how community participation affects the perform
ance of development projects is small but growing.
The two studies that use data from a large number
of projects and have paid most attention to the econo
metrics issues find that community participation leads
to improved project performance.13-1-1 Further,
community-based lending schemes have higher re
payment rates if their membership has higher indi
cators of social cohesion.15 In addition, there is a
rapidly growing body of work linking membership
in social and economic groups to accelerated upward
income mobility.16
Ideally, data on a large number of nutrition proj
ects will become available so that similar analyses can be
undertaken. Can nutrition programs empower com
munities beyond their immediate concerns? And can
community-based nutrition initiatives foster an increas
ing adherence to human rights by a wide range of ac
tors? These questions remain to be answered, but the
signs are promising. Several community nutrition proj
ects have served to stimulate other decentralized devel
opment activities. In Sri Lanka, for example, the nutri
tion component of a World Bank-supported poverty
alleviation project used participatory approaches to en
hance nutrition awareness and improve feeding prac
tices. The project used nutrition as an entry point to
poverty alleviation, by combining it with community
infrastructure development, savings, credit, and micro
enterprise development in a phased manner. In a set
ting characterized by top-down development planning,
the project demonstrated that community ownership
could accelerate positive change.17
4.2 The Implications of Some
Global Phenomena for
Nutrition
The globalization of financial markets in the ab
sence of appropriate oversight and governance has
led to financial crisis, which in East Asia has turned
into a human resource crisis. We highlight these rela
tionships and their implications for public policy
with a case study of Indonesia—the country that has
been hardest hit by the Asian crisis in terms of in
vestments in children. Increasing trade liberalization
is generally thought to spur overall economic
growth. But the increasing openness of developing
country markets to food combined with the failure
of developed countries to reciprocate may well pro
duce a situation that denies developing countries ac
cess to high-income markets for their exports. In ad
dition, different standards of food safety between
importers and exporters may lead to concerns about
the safety of imported food. As food safety con
cerns heighten, the use of food safety as a trade bar
rier against exports from developing countries may
become a more pressing concern. We also consider
the implications of the decreasing costs of informa
tion flows, including how the new information and
communication technologies can be best used to
help accelerate reductions in malnutrition. The freer
flow of capital and people across national bounda
ries has been mirrored by an increasing migration
from rural to urban areas, and the implications of
this increased rate of migration are discussed in this
section of the chapter as well.
Globalization of Financial Resources
and the East Asian Crisis:
Implications for Nutrition
The East Asian financial crisis, which began in July
1997, is a reminder of how unreliable the past can be as
a guide to future events. In one year (1997-98), per
45
Iona
ON PRIMARY HEALTH CARE IN COMMUNITY HEALTH
A BI-MONTHLY Bl
HEALTH C8U
328. V Main. I Bleak
Issue 19th August 1991
NUTRITlWrCHECK BY
In Fiona Plus issue 4 we published a weight-for-length chart for infants and small children up
to 100 cm in height. This is reproduced in this issue for continuity in checking nutrition.
Weight-for-Length Chart
Length
Mimimum Weight
.Length
Minimum Weight
55 cm
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
3.5 kg
3.7
3.9
4.1
4.4
4.6
4.9
5.25.4
5.6
6.0
6.2
6.4
6.7
7.0
7.2
7.5
7.8
8.0
8.2
8.4
8.6
8.8
78 cm
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
9.0 kg
9.2
9.4
9.6
9.8
9.9
10.1
10.2
10.4
10.6
10.8
11.0
11.2
11.4
11.6
11.8
12.0
12.2
12.5
12.8
13.0
13.2
13.5
A BI-MONTHLY BULLETIN ON PRIMARY HEALTH CARE IN COMMUNITY HEALTH
B Fiona "PlusE
Issue 19th August 1991
sFiona-Hlus Focus s.
Issue 19th August 1991
"Fiona
STANDING ORDERS FOR PRIMARY HEALTH CARE
Signs & Symptoms
Medicines
Baby below 1 year
Small child 1-3 years
Older Child 4-13 Years
Adult
Suggestions
Abdominal pain without
Belladonna tab
Carry baby in
1/4 tab 3 x /day x 2 days
1/2 tab 3 x /day x 2 days
1/2 tab 4 x /day x 2 days
Hot Water Bottle to abdomin. Send to dr. after 2 days
vomiting
Antacid tab
upright position
1/4 tab 3 x /day x 2 days
1/2 tab 3 x /day x 2 days
1/2 tab 4 x /day x 2 days
Abscess of skin
Warm salt water
Compress 4 x /day
same
Same
Same
Anaemia and weakness
Iron with folic acid tab
1/4 tab 2 x /day x 30 days
1/2 tab 2 x /day x 30 days
,1/2 tab 2 x /day x 30 days
1 tab 3 x /day x 30 days
Nourishing food. Look for bleeding.
Asthma, short of breath
Aminophyllin tab
1/4 tab 3 x /day x 2 days
1/2 tab 3 x /day x 2 days
■ 1/2 tab 3 x /day x 2 days
1 tab 4 x /day x 2 days
Send to doctor after 2 days.
Bleeding after delivery
Ergotamine
1 tab 3 x /day x 2 days
Send to doctor if serious.
Burns
Gentian violet 1%
Apply to possible infected areas.
Same
Same
Same
Send to doctor if serious.
Constipation
Ispaghule (Isapgol)
1/2 tsp 1 x /day
1/2 tab 2 x /day
1/2 tsp 3 x /day
1 tsp 3 x /day
Drink plenty of water.
Cough only
Cough sedative tab
1/4 tab (crushed) 4 x /day
1/2 tab (crushed) 4 x /day
1 tab (sucked) 3 x /day
1 tab (sucked) 4 x /day
Send for Xray after 15 days.
2 tab 2 x /day x 5 days
Send for Xray if blood in sputum.
Rub with soft stone
Apply after soaking in soapy water.
Cough and sputum
Trimethoprim tab
lus s
Open pus with sterile needle
1/4 tab 2 x /day x 5 days
1/2 tab 2 x /day x 5 days
1 tab 2 x /day x 5 days
Cracked heels
Vaseline
Cracked lips
B complex tab
1/2 tab daily
1/2 tab'2 x /day
1 tab 2 x /day
1 tab 3 x /day
Nourishing food best.
Cracks between toes
Fungicidal ointment
Keep feet clean
Apply daily
Same^^
Same
Apply after soaking in soapy water.
Diarrhoea, mild
Furazolidone
1/4 tab (crushed) 3 x /day x 2 dats
1/2 tab (crushed) 3 x day xroys
1 tab^ffushed) 3 x /day x 2 days
1 tab 4 x /day x 2 days
Report to doctor if stools Joloody
Diarrhoea, severe
Pehydration (ORS) fluid
Give frequently after each motion.
Give often to stop thirst.
Give 1 cup after each motion
May need 3-4 litres/day
Give until diarrhoea stops.
Ear infection
Tetracycline eye/ear ointment
2 drops into infected ear
Same
Same
Same
Warm ointment before putting in, then lie on other side 20 minutes.
Eye infection
Tetracycline eye/ear
ointment
1 drop in infected eye
1 drop in each eye at birth
Same
Same
Same
Warm ointment before putting in.
Fever only
Paracetomal
1/4 tab (crushed) 2 x /day x 2 days
1/2 tab (crushed) 2 x day x 2 days
1 tab 3 x /day x 2 days
2 tab 3 x /day x 2 days
Send to doctor if drowsy.
Fever and chills
Chloroquine tab
1/2 tab (crushed) daily x 3 days
1 tab daily x 3 days
2 tab daily x 3 days
3 tab daily x 5 days
Take malaria blood slide first.
Headache
Paracetomal
1/4 tab (crushed) 2 x /day x 2 days
1/2 tab (crushed) 2 x day x 2 days
1 tab 3 x /day x 2 days
Aspirin 2 tab 3 x /day
Take aspirin with food.
Haemorrhoids (piles)
Haemorrhoid ointment
Apply as needed after motion
Same
Same
Same
Replace haemorrhoids first. Sit 15 minutes in hot water.______________
Night blindness
Vitamin A tab
1 tab daily x 8 days
1 tab daily x 8 days
2 tab daily x 8 days
Repeat after 1 month if necessary.
Pain in body
Paracetomal
1/2 tab (crushed) 2 x day x 2 days
1 tab 3 x /day x 2 days
Aspirin 2 tab 3 x /day
Take aspirin with food.
Pain in joints
Aspirin
1/4 tab 3 x /day x 2 days
1/2 tab 3 x /day x 2 days
2 tab 3 x /day x 2 days
Menthol balm on joints useful. Hot water compresses 2 x /day.________
Poisoning
Charcoal and milk
Same
Same
Same
Send to doctor immediately.
Pregnancy
Iron/folic acid tab
1 tab 3 x /day x 30 days
Tetanus toxoid injections. Repeat medicines monthly
Give as much as possible
_________ __________________
___________________________
1 tab 2 x /day x 30 days
Calcium tab
Round worms
Piperazine tab
2 tab (crushed) at one time
1 tab 2 x /day x 3 days
2 tab pp/day x 3 days
2 tab 2 x /day x 4 days
Drink plenty of water.
Scabies
Benzyl Benzoate
Apply 1 x daily x 3 days
Same
Same
Same
Wash first with soap and water.
______________________________
Skin, infected
Gentian violet 1%
Apply to infected area
Same
Same
Same
Wash first with soap and water.
Skin, itching
Chlorpheniramine
1/4 tab 2 x /day x 2 days
1/2 tab 2 x /day x 2 days
1/2 tab 3 x /day x 2 days
1 tab 3 x /day x 2 days
Send to doctor if severe.
Skin, rash, dry
Sulphur ointment 10%
Apply 2 x /day to rash
Same
Same
Same
Cover with bandage.
Skin, rash, wet
Calamine lotion
Apply 2 x /day
Same
Same
Toothache
Aspirin
1/4 tab as needed
1/4
; 1/2 tab 3 x /day x 2 days
Same__________________ __ Leave skin uncovered to dry.___________________e___________
Consult dentist. Brush teeth after each meal.
2 tab 3 x /day x 2 days
Oil of cloves
Apply to tooth 3 x /day
Same
Same
Same
Urinary burning
Trimethoprim tab
1/4 tab 2 x /day x 5 days
1/2 tab 2 x /day x 5 days
1 tab 2 x /day x 5 days
2 tab 2 x /day x 5 days
Vomiting
Avomine
1/8 tab only as needed
1/4 tab only as needed
1/2 tab as needed
1 tab as needed__________ Send to doctor if pain in abdomen.
Wounds, fresh, deep______ Soap and water____________ Wash thoroughly.
I O N A - F—
Control bleeding.
tab
Pressure dressing.
3 x /day x 2 days
Treat shock.________ Treat shock.
Take plenty of water.
Give T.T. and send for stitching.________________________________________________ ____________ —-------------------------------
The QUAC (Quaker Arm Cirumference) stick as
described in the Current Medicine Scan of the
Christian Medical and Dental Society (May 1990) is
a very useful way to determine whether an older
child is malnourished or not. It measures whether
the arm circumference of a child is as great as it
should be for a child of a particular height.
assistant there.
See Table:-
Table-Markings for QUAC Stick
The QUAC stick is made from a flat piece of
wood 1 cm thick 4cm wide and 140 cm long,
painted white and marked at the appropriate
places with a black ball-point pen. A coat of clear
varnish protects the markings.
The arm circumference tape is made of paper. A
pattern of 10 tapes with centimeter markings is
drawn on a sheet of standard type writer paper. The
pattern is photo copied and cut into strips 2 cm
wide and 28 cm long. These paper tapes will be as
accruate as the pattern. They provide a check from
being drawn too tight during the measuring proce
dure because they tear easily. Replacement cost is
practically nothing. It is efficient to measure chil
dren ranging from 5-10 years of age and children
taller than 133cm are not included 200 children
can be checked in each hour.
An assistant measures the arm circumference at
the mid-point of the left upper arm of each child.
Another assistant writes this measurement on a
small piece of paper and gives the paper to the
child. The child then goes to the QUAC stick some
distance away and hands its paper to a 3rd
A.4 Assistant stands the child agains. The QUAC
stick and calls out the marking at his height. This
figures is written on the paper slip underneath the
arm circumference figure. After the measuring
session the two figures on each slip are compared.
18 the first figures (the child's arm circumference)
is less than the second figure the child is counted
as “malnourished”.
The percentage of malnourished children'can thus
be recorded and compared from time to time.
Fiona Plus is a free bi-monthly bulletin on primary health care in community health, being brought out by the
Christian Medical Association of India, the official health agency of the Protestant and Orthodox churches in
India, a related ageny of the National Council of Churches and concerned with the promotion and
maintenance of health of all people, irrespective of caste, colour, creed or community.
Please let us know the name and address of any individual or instition for our mailing list, whom you feel
could be assisted by the receipt of this free bulletin in our efforts to create awareness of primary health care in
community health.
Editor
Dr. Sukant Singh
Head. Dept. of Community Health, CMAI.
Managing Editor
Ms. L.M. Singha
Communications Officer, CMAI.
Consultant
Dr. R. Seaton
Dept. of Community Health
Published by: Dr. D.S. Mukarji, General Secretary, Christian Medical Association of India & Printed at Mayar Printers, New Delhi.
All correspondence may be directed to:
Christian Medical Association of India. Plot No. 2, A-3, Local Shopping Centre, Janakpuri,
New Delhi-110058 Tel:5552046 Telex:76288 CMAI IN Fax:011-5598150
■
-------------------- --
?------------- 1
A BI-MONTHLY BULLETIN ON PRIMARY HEALTH CARE IN COMMUNITY HEALTH
Oom H-X3--3-3
N U T R I T I 0 N
Groundnut cake powder and dried green
plantain powder/porridge
Plantain flour (raw
50 g.
Groundnut cake flour (roasted)
25 g.
Bengal gram
.25 g.
Palm Jaggery
25 g.
Method: The two flours are mixed in hot water and a semi-solid
batter is prepared. Jaggery is prepared in the form of a syrup.
The semi-solid batter is added to the boiling syrup and kept stirred
It is boiled for 10-15 minutes in an open vessel over low fire.
It is served to the infants before- it gets cold.
Preparation of Plantain powder
Raw plantains are peeled and sliced and are well washed
and sun diied. The dried nlantain chips are powdered in a
grinder. The powder can be kept for weeks, if kept dry.
Plantain is largely available and also contribute to acceptability
and palatability in recipes. The protein value is increased by
the added groundnut cake powder and Bengal gram flour.
CHOLAM PORRIDGE
Cholam flour (roasted)
Green gram dhal flour (roasted)
Sesame cake flour
Jaggery
50 g.
15 g.
25 g.'
20 g.
Method: Jaggery solution is prepared and boiled. The roasted
flours are mixed and4 a batter is made with hot water. The hot
batter is poured in small quantities at a time into the
boiling jaggery solution, stirring to a uniform mixture. The
mixture is boilded for 10 to 15 minutes. It is removed from the
fire and served warm to the child as one feed.
CAMBU PORRIDGE
Cambu flour (roasted )
Green gram dhal flour
Groundnut cake flour
Jaggery
Method: Same as for other porridges
.
50 g.
25 g.
22 g.
20 g.
2
RAGI PORRIDGE
Ragi flour (roaster1)
Bengal grate dhal flour (roasted1)
Groundnut cake powder (roasted)
Jaggery
50 g.
15 g.
25 g.
20 g.
Method: Same as for other porridges
THENAI PORRIDGE
Thenai flour (roasted)
Mochai Chai flour (roasted)
Groundnut cake flour (roasted)
Jaggery
Method : Same as for other porridges
Source: Swasth hind
- July 1980
50 g.
15 g.
25 g.
20 g.
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7
Report on State level Workshop for Nutrition Education
Food and Nutrition Board organized one-day workshop on importance of Nutrition
Education and how to promote the Nutrition on 29th August 2002. Participants included
Karnataka Government officials from Health, Women and Child Development,
Education departments, Academicians, NGO staff among others that constituted
approximately 75-80 participants.
Morning was technical plenary sessions that focused on few important issues like feeding
practices for different age groups. Dr. Asha Benakappa was first speaker who spoke on
Breast feeding and infant feeding practices. During the lecture she told the audience that
more than 11 million children all over the world are malnourished. Major reason for this
problem is poor feeding practices. She explained the group that 1780 million liters of
breast milk is wasted every year in the world, as the mothers do no follow best practice as
far as breast-feeding is concerned. Breastfeeding is not only for the infant, but it reduces
the stress hormone in new mother and can calm her down to very great extent. More over
it also helps in child to get its cortical cells activated, which ultimately results in betterdeveloped child. No pre lactates should be given before initiating the breast milk. If one
avoids usage of lactates it is always better.
Even for the infant feeding, she told the group that it should introduced only after child
attains six months of age. Until then just breast milk is enough for the child. This is
because child starts greater body movements only after six months.
Dr. Tara Gopal Das share about the importance of Nutrition education for adolescent age
group and she even shared about the few experiences she had in implementing the
adolescent school health education programme in Chikmagalur district.
Dr. Subhadra Sheshadri shaed about importance of three major micronutrients namely
Iron- deficiency of which could lead to Anemia. She told though Anemia is considered as
not very major problem, it could very dangerous to neglect Anemia is situations like
pregnancy as this could lead to various complications. Vitamin-A - deficiency of which
could lead to poor vision, weaker resistance power, ands sometimes can even lead to
blindness if neglected for long time. Iodine - deficiency of which could lead to mental
retardation. Apart from these she even explained about the various sources of food, which
can provide these nutrients.
Dr. Sumitra explained about dietary practices and chronic illnesses. She during the
lecture told the audience that due to changing life styles and dietary practices we could
lot of chronic non -communicable diseases like Chronic heart diseases, Osteo
porosis,Diabeted etc. By folwing correct dietary practices according to the suggestions of
the physicians and little fatness activities could reduce the chance of aggravating the
situation. And for the people, which might i.e. in the risk group be able to start following
the healthy dietary habit by introducing more fibrous, protein based food rather than fat
and carbo hydrate based foods.
In the after noon session, participants were divided into 5 groups fro group discussions
and presentation of results of group discussion. Following were the groups and topics
allotted the groups. NGO group- Media strategies, Women and Child development
department- Community strategies, Education- school health and nutrition education,
Health - their departmental activities for nutrition promotion and academicians innovative nutrition education strategies for the students.
All the groups presented and the discussions and programme got concluded at 5.00 pm.
KAVERY NAMBISAN
As a young doctor fleeing from the perpetual anxieties of city life, I came to Fakirpur to work in a
hundred-bed hospital managed by nuns. Fakirpur was eighty pothole-ridden dacoit-mfested
kilometers from Patna. Given the bare facilities, we did a decent job of treating those who could
not afford city prices.
Antiquated medicines like tincture of belladonna, ipecacuanha, canninative mixture and plaster of
turpentine were in common use while penicillin was reserved for nasty infections. We were cheap
and reliable. I performed surgery with the naive poise of a fledging, using a hallowed textbook of
surgery as my surrogate boss, friend and adviser. Over the years, I became isolated from the
progressing world of medicine. And when I made mistakes, I found out the hard way.
In my fourth year at Fakirpur, a new administrator took over. Sister Perpetual Succour was a nun
who had taken her medical degree abroad. She was determined to modernise the hospital and
take it to 'new heights of excellence'. Out went the mixtures, plasters and even penicillin; we
prescribed capsules and higher antibiotics. Suddenly realising that the hospital was really very
backward, the nuns went on a buying spree. Patients watched bewildered as some equipment or
the other was unloaded from a truck every week: a new ECG machine, a cardiac monitor, a pulse
oximeter. The nuns worked hard to get donations from the local landowners and merchants. The
expenses went up and so also the bills. The villagers believed that machines and expensive
medicines would somehow provide good health. And they did not complain.
Sister PS was set on making us efficient.. Work started at 0700 hours and finished at 1800 hours
with a 35-minute break for lunch. She set up committees: waste management committee, drug
purchase committee, food committee. She encouraged us to read the foreign journals which she
subscribed to. Aware of the deficiencies in my knowledge I made amends by staying longer in the
library. I walked with brisk steps to the hospital, relied on machines to tell me the diagnosis, did
less and felt triumphant.
Everyone was given a responsibility: I was on the food committee. Instead of the usual thali meal
nerved at the hospital canteen, we had boiled-egg-and-tomato sandwiches wrapped in plastic;
puns and idlis for breakfast were replaced by bread and jam. Easier to serve and less messy. For
some of the staff including me, it felt good, almost fashionable to be munching abacterial, aseptic
sandwiches while reading a journal in the library.
Soon food came to preoccupy me in another way.
An international medical conference was to be held in Mathura which PS kindly recommended
that I attend: a two-day jaunt to the land of Sri Krishna, a chance to meet experts, hospitality and
entertainment
thrown
in.
I
was
happy.
The main symposium during the conference was on Nutrition. Why, when there was all of medical
science? A little thought and I realised that many lives were cut short because of the food people
ate
or
did
not
eat.
The conference was two months away. Being alert to the possibility of impressing people at an
international conference, I decided to present a paper: The importance of Food in Post-operative
Care. I read journals and research papers, prepared slides and realised that it was too dull a
subject to impress people with. So I wrote another: Rare Surgical Cases.
It was a showy piece with spectacular, lurid details about some of the operations I had done that
were in someway connected with eating. I wrote about the chunk of just-eaten meat I had found
in the gut of an undefiled brahmin; the gravel, two pounds of it, that I had evacuated via the
rectum in a eight-year-old; the roundworms wriggling inside the belly of a man whose gut was cut
to pieces from a gunshot; and about the congealed ball of toffee wrappers blocking the intestines
of a young boy Very clever. I could see myself on the podium; and later, the doctors milling
around
me,
eager
to
listen
to
more
heroics.
I sent in both the papers and waited. Two weeks later came the reply that the papers had been
rejected. We have too many submissions, they said, which was a polite way of telling me that
mine
were
inconsequential.
Humbled, I went to the conference, taking the overnight tram to Mathura. I was to stay with Dr
Sadashiv, a friend of a friend in Fakirpur and who was originally from the same area. The doctor
was slightly built and fortyish, with paan-stained teeth and the pinched look of one who thinks too
much. He looked so pensive, I labelled him Dr Sad. He wore terylene bush shirts and scuffed
sandals, spoke good English with a Hindi accent and rode a fourth-hand Bajaj that sounded like
the
ratted
breath
of
am
old
woman.
Dr Sad's wife was a coarse-tongued rustic and they had four children. I shared a cramped little
room with one of his school-going daughters. His clinic was an extension of his house. Outside it,
a once-white board screamed in red letters that he was MBBS, FR - Foreign-Returned. Judging
from the number of times he was being called to the clinic on a Sunday evening, I reckoned that
Dr
Sad
had
a
flourishing
practice.
We had a simple dinner of deal, chapatti and egg bhujiya. "I love food but keep things simple,"
said Dr Sad. "This meal hasn't cost more than ten rupees." Sad could get away with serving
dinner to a guest and then announcing how cheap it was. Later, over elaichi tea, we talked.
He had started m the '60s as a compounder, worked his way into Patna Medical College and then
gone to England for a while. He came back after eight months because they objected to his
chewing
paan.
It was not an irony that the money he made was inversely proportional to the quality of his work.
Sad belonged to that rare breed of doctors who believe that their work should be superior to what
they earn. I was nonplussed and slightly annoyed by his simplicity and told him in elaborate detail
about the changes in our hospital in Fakirpur, about the monitors and scanners that had made
work efficient. He was unimpressed. "Sounds like a too-quick transition from a bullock-cart to a
bulldozer," he remarked. "The patients will be paying more but are they getting better health?"
He said - without arrogance -- that he was a good doctor because he made illness more
interesting to the patient. Food had great power over the psyche. "Every prescription of mine
comes with a diet," he said. "One spoon of oil a day, no chicken; a glass of beetroot juice in the
morning for a week, carrot juice the second week and cucumber the third. Patients are happy that
their doctor is so caring." He saw the puzzled look on my face. "It's a carefully thought-out
strategy. Have you ever wondered about the money patients have to spend on medicines? We
know that the drug companies make huge profits on everything they market. A patient can buy
half a kilo of carrot or beetroot or cucumber for the price of a vitamin capsule." He looked intently
at me. "You service the same type of community as me. I'll give you a bit of advice. Don't
prescribe more than one or two medicines. But prescribe a diet, always. What does it cost you? it
is one way of ensuring that poor people spend their precious money on some decent
nourishment."
I listened with mild contempt. He was making too much of a fuss about the food people ate. And
what could I do about drug companies making profits? As if that was a doctor's business.
Pondering over it later that night, I decided that he was an old-fashioned stick-in-the-mud whom I
had
to
suffer
for
a
couple
of
days.
Imagine my astonishment when Sad told me that he was to speak at the conference. Could he
have written a paper so imposing and scholarly that it pipped mine to eligibility? He was secretive,
and
would
not
talk
about
it.
Mathura had donned a festive look, with banners screaming Welcome. Distinguished delegates
arrived, and were put up in posh hotels. The two days were as hectic, mismanaged, chaotic,
opulent, superficial and meaningful as any conference I had attended in the past. I listened to
lectures and wandered around the drug stalls put up to entice us. I learnt all there was to learn
about the harmful effects of cholesterol, fatty acids, sugars, food additives and alcohol; heard that
the millions who starved in Africa and Bangladesh were being rescued by foreign aid; then
headed for lunch, tea or whatever repast was appropriate for the time of day, I ate paranthas with
mughlai chicken, ghee rice with lamb curry and finished with Agra pedas; carrying my cup of
coffee I staggered back to the conference hall to listen to the Swedish expert talk about the
micronutrients essential to health, and to the Danish dietician advocate a daily dose of twelve
vitamin
tablets
and
two
cholesterol-lowering
capsules.
At tea, I sat in the foyer trying to clear my fogged brain. Delegates zipped about carrying their
complimentary travel bags that came filled with high-protein breakfast bars. Stalls displayed
slimming tablets, easy-to-eat lunches, low calorie biscuits, no-calorie biscuits and health drinks.
Sad stood a little away near the water cooler pulling at his Charminar. His eyes were busy,
thinking. He pointed out to me that the infant food package being sold at one of the stalls was
unbeatable value. "For every thirty tins of the infant formula purchased you got two free packets
of multipurpose protein powder to give poor patients." A long queue had begun to form at the
infant food stall. "It's always nice to help someone while helping yourself Was he being
sarcastic? In any case, I had no interest in infant foods and passed up the opportunity to do
charity. I asked if listening to the eminent speakers had put him in a panic. A rare smile scissored
his face but he wouldn’t tell me about his paper.
The first evening passed pleasantly, with light entertainment, drinks, scrumptious food and a
special appearance by a TV celebrity. She made a touching speech about how doctors were the
cream
of
society.
Replete
with
food,
I
listened.
The second day began with an American surgeon speaking about the treatment of obesity.
"Calories are the scourge of society," he said, his trim, sun-tanned body taut with the sincerity of
his belief. "Fight calories with the same fervour with which you fight any vice. Teach it to the kids:
Calories are evil!" Besides a surfeit of pills to restrain hunger, there was the wiring of jaws to
prevent any solid food being eaten; as there were operations that helped melt away fat. His own
time-tested method was to cut off a portion of the gut and thus limit the absorption of food. If ten
out of the twenty-two feet of intestine were knocked off, the food speeding through the shortened
gut would have less contact time with the intestine. It would pass out without absorption of the
malevolent calories. No calorie build-up, no fat accumulation. Result: you eat and get thin. Among
the hundreds of cases he had done, there were a mere eight deaths and one of them was from a
non-surgical cause. The lady had fallen off the stretcher while being wheeled to the operating
theatre and broken her neck. This surgeon who made calorie-fighting his mission had started a
helpline for the obese in the town where he lived. One had simply to call the number to find
someone
with
whom
to
chat,
over
cake
and
coffee.
On the last day after tea were the free papers. I was feeling a bit sorry for Sad by then. He had
requested that he be the last speaker. With the grand finale of the closing ceremony and the
banquet afterwards, he did not have much chance of being listened to. He had no slides, no
photographs, no text to be flashed on the screen. He asked that the main lights be switched on
and in their glare he looked ludicrous, standing there on the dais in his ill fitting trousers and
bush-shirt.
He had titled his talk 'The Nutritive Value of the Sky'. I shifted uncomfortably in my seat. "I have
studied the food habits of people for eighteen years," he began. "In the rural town I come from,
people eat chapattis, daal, raw onion and green chilli and chew a raw radish or carrot afterwards.
Some families buy a metre-length of sugarcane at the market as a Sunday special. Roasted
wheat, groundnuts or cucumber with salt serve as snacks. Tea is drunk once a day in summer,
twice in winter. For many of the poor, the staple food is sattu - a mix of channa daal and a little
salt, powdered fine and carried in a twist of cloth or a tin. Mixed with water, it is an excellent meal.
Sattu
does
not
spoil
and
so
it
is
never
wasted.
"The mushahars are a rat-eating community in our area. They live on large field rats and eat
house mice for festive occasions. I have an excellent recipe for rat fry, If anyone is interested.
Whether it is sattu, rat meat or chapattis, the caloric value of their diet is 1500 calories a day, plus
or minus 200. They put in eight hours work in the fields on this diet and return home to cope with
housework: drawing water from the well, feeding the cows and collecting dung.
"I learnt in medical college that an average healthy diet for a working man is 3000 calories, for a
woman 2500. Who are they talking about?
"At dinner last night, it occurred to me that there are three categories of eaters: Those who can
afford to choose what they eat; those who have just enough and no choice; and the third, who
have nothing. The last group lives on any food that comes their way. They live on pavements and
in the slums, make our cities ugly and spread disease. We, who belong to the first group, would
like them to disappear. But we're good people, we don't go about killing others. Instead we quietly
let them starve while we refine our food habits and expand our choices." Sad paused to catch his
breath "Last night a doctor I know well ate and drank enough to please the drug company which
hosted the dinner. And them vomited it all out in the garden at the back of this hall. While he was
thus lightening himself, a few feet away at the garbage bin where the food we wasted was being
dumped, I saw two children and a woman. They picked out half-eaten rotis, chicken bones and
crumbs of laddu and stuffed it in a plastic bag. For them too, it was a festive meal.
"I have learnt a great deal about food, from the experts here. I wonder: how do some people several millions in fact -- survive on a diet that you or I or my patients would starve on? Is there a
nutritive value in the sky that looks down on their labours, in the air they breathe, in the sunlight
that falls on them as they work, to supplement their power lunches? May we have a long and
mindful discussion about the true meaning of malnourishment and its causes? In college I learnt
about first-degree, second-degree and third-degree malnutrition. Seeing those children pick at
wasted food last night, I thought instead of first, second and third-degree murder. Who is guilty?"
I sat in my seat in the fifth row drinking in the scene. The Americium surgeon, the Danish
dietician, the Swedish micro-nutritionist and our own specialists and super-specialists were
seated in the out rows: clones of clones sweating manfully in sober suits, their faces stony,
impassive. Here was a doctor with his sorrowful, paan-stained smile and his sandpaper voice
slipping in the barbs that none of them could counter. Compared to him, they looked second-rate.
There was silence followed by polite applause. Any questions, asked the expert who had chaired
the session. Someone cleared his throat, of embarrassment. No questions We filed quietly out of
the trail to have tea and samosas and then wait for the closing ceremony. Dr Sad stood near the
water cooler, drinking glass after glass of water. He looked crestfallen. "There was no response,"
he said. "Absolutely none. I thought that at least a few might appreciate what I was trying to
say..."
A doctor by profession, Kaveri Nambisan is also the author of The Truth (almost) About Bharat,
The Scent of Pepper, Mango-coloured Fish and On Wings of Butterflies.
Other short-listed entries will be available on the site tomorrow and the day after.
»
s
I KarnatakaMT
State
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Nutrition Poeict
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(Department of Women andChiM(Development
M.S. Building, Vidhana Veedhi
Bangalore 560 001
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KAMAA1AKA STATE NUTRITION POLICY
"f,,., -<- ,
g< |
1. Introduction1
2. Heedfor Nutrition (Policy
3.
Objectives
4.
Current nutrition situation in IQimata^a.
5.
On going nutrition intervention programmes in
TLfirnatahg
6.
Causes ofmalnutrition
7.
Tdjimatabg State Nutrition Policy
8.
Plan of action
- Short term strategies
- Long term strategies
9.
Modalities of implementation
- State level
- (District level
- Sub (Division [eve!
10.
Nutrition Surveillance System
11.
Pfirust areas in Nutrition Policy
FACT SHEET
NUTRITIONAL STATUS OF CHILDREN IN KARNATAKA
___,Urban 21%
Birth Weight
<
than 2500 g"^
Rural 14%
Infant feeding
67%'
53%
4-9%
Exclusive breast feeding
Timely supplements
Under nourished infants
Malnourished children! 1-5 years)
Normal
Mild
Moderate
Severe
7.2%
45.2%
45.2%
2.4%
Vitamin A deficiency in children
Rural
Urban Slum
Tribal
0.3%
1.1%
0.7%
Endemic Goitre regions
Chickamagalur
Kodagu
Dakshina Kannada
Uttara Kannada
41%
23%
14%
11%
Iodized salt
Rural 76%
< than 30 ppm iodine^-'--.
'' Urban 51%
Anaemia in children
Mild
Moderate
Severe
19.6%
43.3%
7.6%
Enrolment of Children in ICDS programme
6 months - 1 year
1-3 years
3-6 years
:
:
Supplementary Nutrition
0-3 years
3-6 years
:
:
Mid Day Meal
Current Beneficiaries
Dropout rate
' :
312448
lOffe,681
1384533
AREF .
AREF - 2 days
Egg - 1 day
Indigenous recipes - 4 days
56.21 lakh children
Reduced from 32.83 % to 11.8%
NUTRITIONAL STATUS OF MOTHER
CED
:
36%
Nutrient Adequacy
Lactating (%)
Pregnant (%)
Macronutrients
Adequate
66-98
Minerals
47-85
61-68
Vitamins
39-100
19-100
ICDS: Enrolment for supplementary Nutrition
Number
Enrolment
Pregnant and
486995
Lactating
Percent prevalence of Anaemia
Normal
57.8%
Pregnant
Women
51.3%
Lactating
women
54.3%
Mild
26.3%
20.9%
30.7%
Moderate
13.6%
24.9%
12.6%
Severe
2.3%
2.9%
2.4%
Anaemia
Women
Source:
1.
NNMB-2000.
2.
NFSH-2- 1999.
3.
Multiple indicator survey - 2000.
4.
Directorate of Health & family welfare. .
KARNATAKA STATE NUTRITION POLICY
1.
INTRODUCTION
The concept of health is the state of the complete physical, mental and
social well being. Good health can be achieved through good nutrition. The
nutrition well being of all people is a prerequisite condition for the
development of societies and it should be the key objective for the progress
of human development.
Malnutrition is a silent emergency but the crisis is real and its persistence
has profound and frightening implications on children, society and the
future mankind.
Eradicating hunger and malnutrition is within the reach of mankind.
Political will, well conceived policies and concerted activities at national and
state level can have a dramatic impact on these nutritional problems. The
basic goal of protecting and promoting nutritional well being for all will be
achieved only through a combination of policies involving various sectors at
various levels of responsibility.
2.
, .
NEED FOR STATE NUTRITION POLICY
The National Nutrition Policy (NNP) was approved by the government of
India in 1993. The Government adopted this policy in recognition of the
magnitude of the problem of under nutrition in the country despite the
dramatic increase in food production. The need for development of State
Nutrition Policy is recognized in view of the diversity and heterogenicity in
the causation and magnitude of different nutritional problems of the state
as revealed by the nutrition surveys (NNMB, NFHS etc,) in the state.
3.
OBJECTIVES
The major objective of the nutrition policy is to identify and reinforce
intersectoral approach that leads to sustainable benefits in terms of
nutrition health and well being of individuals, community and population.
Karnataka State, Nutrltlongaljcx
To achieve this objective, identification of short term, intermediate and long
term strategies either through direct policy changes or indirect institutional
changes is essential.
The state nutrition polidy has the following specific objectives:
1.
Reduction of severe and moderate malnutrition among under five
children, especially under two years.
2.
Reduction of micronutrient deficiencies i.e., Iron, Iodine and
Vitamin A deficiencies.
4.
3.
Reduction of maternal malnutrition
4.
Reduction of low birth weight babies.
CURRENT NUTRITION SITUATION IN KARNATAKA
NUTRITION PROFILE
I.
Protein Energy malnutrition
Nutritional status is a major determinant of health and well being of
children. Inadequate access to food and repeated infections are associated
with poor nutritional status among children. NNMB (1996-1997) data
indicated that majority of children under five years are malnourished. The
children considered normal were only 9.4% however, mild, moderate and
severely malnourished includes 39%, 45.4% and 6.2% respectively.
Fig 1: Percentage of children (1-5 years) malnourished according to
Gomez classification
Source: Report of Second Repeat Survey rural 1996-1997
2
NNMB Tribal survey 1998-99 revealed that the prevalence of mild,
moderate & severe malnutrition among children under five years of age was
46.2, 43.0 per cent and 2.3 per cent respectively. However, normal children
in tribal areas were 8.50%.
Fig 2: Per cent distribution of pre school children (1-5 years) according to
Nutritional grade (Boys & Girls pooled)
NNMB report of the tribal survey 1998-1999.
II. Micronutrient Malnutrition
Vitamin A Deficiency
The NNMB reports over the years indicated that Vitamin A deficiency
(Bitot’s sport) was high in urban slums and comparatively lower in tribal
children compared with rural counterparts. However, the trends over the
years also showed significant decline in the per cent prevalence of Vitamin
A deficiency from 2.31% (1975-1979) to 0.5% (1996) and currently (2002)
further reduced to 0.3 per cent in rural areas. Among urban slums and
tribal children the reduction were 7.1-1.1% and 1.4-0.7% respectively.
The prevalence was higher among children from urban slums and tribal
areas when judged from W.H.O criteria of public Health significant ie.0.5%.
3
Table:
Vitamin
1
A
deficiency trends
in
children
from
rural
areas
(NNMB report Karnataka)
\
Year
Per cent prevalence \
1975-76 •
2.3
1988-90
1.1
1996-97
0.5
__________ 0.3________ J
2002
Table: 2 Vitamin A deficiency trends in children from urban slums (NNMB
report Karnataka)
/
\__
Year
Fer cent prevalence
1975-82
7.1
1993-94
1.1
__ y
Table: 3 Vitamin A deficiency in Tribal pre-school children (Karnataka)
<
Survey
Fer cent prevalence
NNMB Tribal Survey 1985 - 1987
1.4
0.7
^NIN Jenu Kurba Tribal survey 1998
J
National survey of blindness report of 1986-1989 shows that prevalence of
vitamin A deficiency in rural areas of Karnataka to be lower than all Indian
average. The prevalence was also lower when compared to neighbouring
states like Andhra Pradesh and Tamilnadu but higher compared to Kerala.
4
Table: 4 National survey of Blindness 1986-89. Prevalence rate of Vitamin A
Deficiency in 0-6 years population
State
Rural
Prevalence Rate
1.57
Karnataka
Urban
\
Prevalence Rate )
4.9
Other southern states
Andhra Pradesh
2.78
1.36
Tamilnadu
2.03
10.10
Kerala
0.49
1.45
India (Pooled)
6.54
4.77
Iodine Deficiency
Goitre or the enlargement of the thyroid gland is the most common and
visible manifestation of iodine deficiency and Goitre Prevalence Survey, is
used as community diagnostic tool for identifying iodine deficiency areas.
Surveys conducted in Karnataka state during 1988-1991 revealed that four
districts
of
Karnataka
namely,
Chikkamagalur,
Dakshinakannada,
Uttarakannada and Kodagu had prevalence of more than 10% of Goitre
thus forming the endemic districts of the state. However, the surveys
revealed that none of the districts were free from goitre though not from
public health significant point of view.
The prevalence was more among female and in the age group of 12 to 48,
warranting implementation of Iodine Deficiency Control Programme by the
provision of iodised salt for all.
5
JjgraaMa Stiitn Nutrltlna Pollr
Table: 5 Per cent prevalence of goitre in different districts in Karnataka
1988-91
Districts
Chikkamaglur
Prevalence
41.11
Kodagu
23.12
Dakshina Kannada
14.18
Uttara Kannada
10.67
Shimoga
6.90
Bidar
5.37
Gulbarga
4.85
Bijapur
4.6
Kolar
2.97
Belgaum
2.53
Tumkur
2.23
Hassan
2.04
Raichur
1.94
Bangalore (rural)
1.79
Bangalore (urban)
1.73
Mysore
1.62
Dharwar
1.57
Mandya
1.20
Bellaiy
1.00
Chitradurga
0.99
4.91
y^Totai
)
Goiter re-survey under NIDDCP-2003
Resurvey report conducted in Chickmaglore and Kodagu district indicated
the prevalence of goiter to be 25% and 8.67% respectively. However, data
indicated decline in the prevalence rate of goiter compared with 1988-91
survey which may be accounted for supply of iodized salt. Since 1990 in
these district.
6
Iodization of Salt
In India, common salt is iodized with potassium iodate to an iodine content
level of 30 ppm and to ensure that by the time the salt reaches the retail
level it still has at least 15 ppm of iodine.
Table: 6 Per cent prevalence of goiter in Chickmagalore & Kodagu district
Z"
District
Prevalence
1988-1991
2003
Chickamagalur
41.11
25.0
Kodagu
23.12
8.7
Source: Government Medical college, Mysore
Table: 7 Status of iodine content in salt samples from retailers in Karnataka
Source: AICRP-HSc(F&N), Bangalore Centre, UAS, Bangalore
Iodine content in foods
Iodine deficiency results from geological rather than social and economic
condition. The problem is aggravated by environmental factors such as
deforestation and soil erosion. Unlike other micronutrients iodine does not
occur naturally in specific foods rather it is present in soil and is imbibed
through foods grown on that soil. Ideal situation would be to meet the daily
needs of iodine from the natural foods grown in iodine rich soils.
Food samples from urban areas were found to contain more iodine than the
rural samples. Iodine content of samples from coastal and hilly zone was
found to be lower compared with eastern dry zone. Large variation in iodine
content was found in samples from different food group.
7
.Karnataka Stain NuMHnn Pntlr
Table: 8 Mean + SD of Iodine Content in food samples (pg/100g) from three
Agro Climatic Zones of Karnataka.
Food
groups
Eastern dry
Hilly
Coastal
Eastern dry
Hiiiy
coastal
Cereal grains
106.6+15.1
35.2+15.8
19.4+6.2
64.9+20.9
36.7+7.2
16.0+1.16
Pulses and
Legumes
76.2+37.2
35.7+1.3
20.0+6.1
62.9+36.8
63.2+13.5
16.1+1.2
Leafy
vegetables
144.6+50.1
44.8+18.3
28.1+7.3
152.7+89.2
44.6+13.8
71.9+41.2
Roots and
Tubers
97.4+46.3
30.7+7.2
16.1+3.1
36.7+15.9
32.6+0.0
20.0+1.5
Other
vegetables
100.0+69.6
33.1+9.0
16.4+6.8
93.6+49.6
38.9+11.6
22.9+5.6
Nuts and oil
seeds
97.8+7’3.0
43.7+35.5
13.7+5.3
93.0+12.0
56.6+25.2
20.4+6.8
Condiments
and spices
93.4+51.3’
23.8+2.8
19.9+8.2
76.6+52.1
34.1+8.5
24.0+2.6
Rural
Urban
Fruits
68.4+55.8
25.8+9.5
13.9+5.9
45.6+38.5
33.8+9.3
21.7+14.5
Meat and
Poultry
41.0+18.1,
34.3+8.3
46.6+9.1
108.4+0.0
61.8+0.0
48.6+0.0
Milk_______
153.0+39.0
143.3+81.8
89.8+18.7
147.5+16.2
14.3+6.3
42.0+17.8
Source: AlCRP-HSc(F&N), Bangalore Centre, UAS, Bangalore
Iron deficiency
The most common cause of Anaemia is iron deficiency, which is due to
inadequate intake of iron in the daily dietary. Anaemia is a serious concern
specially for young children because it can affect the overall development of
the child and also scholastic achievement.
Studies on prevalence of Anaemia among children in Karnataka.
In Karnataka, haemoglobin levels were tested for children in the age group
6-35 months. On the whole 71 per cent of these children had some level of
anaemia including 20% who were mildly anaemic (10.0-10.9 g/dl), 43 per
8
Knrnntnkn -Itntn NuMtlan Pnlfev
cent who were moderately anaemic (7.0-9.9 g/dl) and 8 per cent who were
severely anaemic (< 7.0 g/dl).
Anaemia in relation to background characteristics
NFHS-2 Karnataka, 1999 report indicated that children in the age group
12-23 months and with factors such as normal weaning, children with
higher birth order, children living in rural areas and children whose
mothers were illiterate are found to be particularly affected with high levels
of anaemia. Despite these differentials, anaemia is very wide spread in
Karnataka.
9
Karnataka Slate Nutrition Pallr-
Table: 9 Per ccntage of children classified as having iron-deficiency anaemia
by selected background characteristics, Karnataka, 1999.
Severe A
anaemia
Mild
anaemia
Moderate
anaemia
6-11 months
12-23 months
24-35 months
23.5
20.3
16.5
45.0
48.0
36.8
Male
Female
17.5
21.9
45.8
40.8
9.4
5.8
1
2-3
4-5
6+
16.4
21.8
22.2
13.4
40.8
44.2
40.8
60.7
5.5
8.7
9.3
7.7
Urban
Rural
19.5
19.7
41.7
44.1
5.1
8.9
Illiterate
Literate< middle school complete
Middle school complete
\High school complete and above
19.2
21.1
17.7
20.3
46.9
40.5
47.7
36.4
11.4
4.0
5.9
2.9 y
Back ground characteristics
Age of child
.
'
2.2
9.2
9.1
Sex of child
Birth order
Residence
Mother’s education
Source: NFSH-H, 1999
According to the study conducted by university of Mysore in urban slums
25-90% of girls were found to suffer from Anaemia. However, the study
conducted by Division of Home Science in rural areas of Devanahalli taluk,
Bangalore District revealed that 84% of boys and 79% of girls in rural
schools suffered from varying levels of anaemia.
III.
MATERNAL NUTRITIONAL STATUS
Anthropometric measurements such as height and weight data were used
to calculate body mass zindex(BMI) which is calculated as weight in
kilograms divided by the height in metres squared (Kg/m2). The height of
an adult is an outcome of several factors including nutrition during
childhood and adolescence. The cut off point for height, below which a
women can be identified as nutritionally at risk, varies among populations,
but it is usually considered to be in the range of 140-150 centimeters(cm).
10
Nutrition pnljcy
NFHS-2 (1999) found a mean height for women in Karnataka to be 152 cm.
However, they are one cm taller than the mean height for women.
The BMI for women in Karnataka is 20. Malnutrition in women is
measured in terms of chronic energy deficiency (CED). CED is usually
indicated by a BMI of less than 18.5. More than 1/3 rd of women in
Karnataka have a BMI below 18.5, indicating a high prevalence of chronic
energy deficiency. However, 11% of women are with a height less than 145
cms indicating the risk of difficult deliveries and also prone to deliver low
birth babies.
Table: 10 Mean height, Per centage with height below 145 cm, BMI and per
cent with BMI below 18.5 kg/m2 of women, Karnataka 1999.
z
Height
Age
Mean
Height
(cm)
Percentage
below 145 (cm)
7.7
BMI
Percentage
with BMI
Mean BMI
Below 18.5
kg/m3
45.6
19.0
15-19
152.1
20-24
151.9
7.4
19.1
25-29
152.4
9.3
20.0
39.4
30-34
151.9
9.7
20.6
35-49
151.8
11.3
21.3
37.6
33.2
48.5
J
Source: NPHS-B, 1999
According to NNMB report 1998-1999 adult tribal population were found to
suffer from chronic energy deficiency (CED). Per centage of women
(55.4%)with CED were found to be higher than men(49.3). Judging from
weight for height criteria around 43% of women were normal.
11
Table: 11
Per cent distribution of tribal adult population according to BMI
(1998-1999)
Category
Men
Women
CED
(18.5)
49.3
BMI grade
Normal
(18.5-25)
49.8
Over weight
(25-30)
0.9
55.4
43.4
1.3
Source: NNMB Report J 998-1999
NNMB report 2001-2002 indicated that 34.5% of males and 31.1% of
females from rural areas were normal as judged from BMI. However, lower
weight and severe wasting ranged from 19-22 and 5-8% respectively.
Table: 12 Per cent distribution of adults (>18 yrs) from rural areas according
to BMI
V
Category
CED III
(16)
CED II
(16-17)
CED I
(17-18.5)
Low weight
(18.5-20)
Normal
(20-25)
Obese
(25-30)
Obese II
_______
Males
Females
5.3
8.3
8.3
10.3
22.6
23.1
22.1
19.3
34.5
31.1
6.8
7.0
0.3
0.9
J
Source: NNMD-2001 -2002
Well nourished mothers gain an average of 10-12 kg of weight during
pregnancy and deliver babies whose mean birth weight exceeds 3 kgs. The
NFHS-2 (1999) report also indicated that women’s height can be used to
identify women at risk of having a difficult delivery since, small stature is
often related to small pelvic size. The risk of having a baby with a low birth
eight is also higher for mothers who are short.
Nutritional status of the infants is closely related to the maternal
nutritional status during pregnancy. Maternal nutritional status is the
12
,
...
,
i
,
■< .
.Kuruntnka Stpitfi flutrftkin Policy
most decisive factor in preventing low birth weight babies since, birth
weight of infants is the most important determinant for child survival, it is
necessary to tackle the problem of maternal malnutrition to prevent not
only low birth babies and for child survival but also to bring down the
maternal mortality perse.
Anaemia In women
Anaemia being a serious problem in India NFHS-2 measured the
haemoglobin levels of women aged 15-49 years and results indicated that
41 per cent of women had some degree of Anaemia. Prevalence was higher
for pregnant women and lactating women compared with other women.
Iron and folic acid tablets are provided to women in order to prevent
anaemia during pregnancy.
Fig 4: Anaemia in women (NFHS - 2, 1999)
Fig 5: Anaemia in pregnant women (NFHS - 2, 1999)
13
Karnataka StatatiutrUlon Pnllnv
Fig 6: Anaemia in Lactating women (NFHS - 2, 1999)
Low birth weight babies
Weight at birth is a key indicator of the infant’s health and survival
capability. Under government of India’s child survival and safe motherhood
programme, all children are to be weighed at birth and their weight is
entered in a birth registration card given to the parent. About 58 per cent
urban and 32 per cent rural children below age five years were weighed at
birth. Based on documentary entry and recall, 21 per cent from urban and
14 per cent rural are reported to have weighed less than 2500 g at birth.
Low birth weight is a major contribution to neonatal mortality, maternal
nutrition being the major cause. The other risk factors are age, height and
weight of the mother, interval between pregnancies and anaemia etc.
IV.
INFANT FEEDING PRACTICES
Infant feeding practices and nutrition have sufficient effects on child
survival. Breast feeding improves the nutritional status of young children
and reduces mortality and morbidity. Breast milk not only provides the
child with important nutrient but also protects the child against infection.
The Baby Frien'dly Hospitals initiative, launched by the United Nations
Children’s Fund (UNICEF)
recommends initiation of breast feeding
immediately after child birth. The World Health Organisation (WHO) and
UNICEF recommends that infants should be given only breast milk for the
first six months of their life. However, according to NFHS-2 data 67 per
14
cent of infants in Karnataka are exclusively breast fed which is higher than
the national level of 55 per cent.
By age seven months, adequate and appropriate supplementary foods
should be added to tire infant’s diet in order to provide sufficient nutrients
for optimal growth. It is recommended that breast feeding should continue,
along with complementary foods, through the second year of life or beyond.
However, in Karnataka (NFHS-2) the introduction of complementary food
was delayed for a substantial proportion of children. Only 38 per cent of
breast feeding children age 6-7 months consume solid or mushy foods.
This proportion increased to 75 per cent or more at age 16-35 months.
Only 40 per cent of breast feeding children age 6-9 months receive solid or
mushy food as recommended. However, comparatively better than tire level
of 35 per cent for India as a whole.
V.
DIETARY INTAKE
Nutrients that are obtained through food have vital effects on physical
growth and development, maintenance of normal body function, physical
activity and health. Nutritious food is, thus needed to sustain life and
activity hence, diet must provide all essential nutrients in the required
amounts. Requirement of essential nutrients vary with age, gender,
physiological status, physical activity and stress. Eating too little food
during the vulnerable periods of life and eating too much at any age can
lead to harmful consequence. Carbohydrates, fats and proteins are
macronutrients needed in large amounts and vitamins and minerals
constitute the micronutrients required in small amounts.
Requirements of macronutrients are met to a great extent in the diets of
adults and children as per the NNMB-2000 data for rural population.
However, nutrients such as iron, vitamin A, B-complex vitamins and folic
acid the adequacy compared to RDA is not upto the satisfactoiy level. The
adequacy level of nutrients specially in terms of minerals and vitamins
have been very low for children in age group 1-3 years.
15
Karnataka state. Nutrtttnn Paltry
Table: 13 RDA and Per cent adequacy of Macronutrients consumed in the diet
of rural population (NNMB-2002)
/
Group
Particulars
Protein (q)
Total fat (g)
Energy (Kcal)
RDA
RDA
RDA
%A
%A
%A
Sedentary work
60
100
20
179
2425
97
Moderate work
60
104
20
147
2875
84
Man
Women
Sedentary work
60
89
20
157
1875
112
Moderate work
60
92
20
121
2225
96
Pregnant
(Sedentary)
Lactating
(Sedentary)
65
92
30
117
2175
105
68
84
45
66
2275
98
1-3 years
22
84
25
44
1240
59
4-6 years
30
89
25
62
1690
62
7-9 years
41
81
25
70
1952
66
54
77
22
102
2190
74
Girls
57
70
22
92
1970
79
Boys
70
69
22
122
2450
79
Children
Boys
10-12
. 13-15
Girls
65
72
22
108
2060
91
Boys
78
68
22
135
2640
81
63
85
22
116
2060
99
16-17
Girls
Note: RAD - Recommended Dietary Allowances
Source: Nutritive value of Indian foods, ICMR, 2000.
16
7
. .
— .
Table: 14
.
.
Kamataka.State. Nutrition Policy
.
RDA and Per cent adequacy of Minerals consumed in the diet of
rural population (NNMB-2002)
/
Iron (mg)
Calcium (ma)
Group
Particulars
RDA
%A
RDA
%A
Sedentary work
400
184
28
63
Moderate work
400
185
28
66
Sedentary work
400
170
30 '
52
30
56
\
Man
Moderate work
400
157
Pregnant (Sedentary)
1000
. 85
Lactating (Sedentary)
1000
68
30;
61
1-3 years
400
50
12
37
4-6 years
400
62
18
38
7-9 years
400
85
26
36
600
79
' 34
35
600
72
19'
62
600
109
41
36
600
88
28
51
Women
. Children
Boys
38:
10-12
Girls
Boys
'
13-15
Girls
Boys
500
151
50
32
500
138
30
59
16-17
Girls
Note: RAD - Recommended Dietary Allowances
Source: Nutritive value of Indian foods, ICMR, 2000.
17
y
Jiarnatak^.Stute Nutrition Policy
Table: 15 RDA and Per cent adequacy of Vitamins consumed in the diet of
rural population (NNMB-2002)
z
Group
Particulars
Vitamin Thiamine Ribofla
vin
A (mg)
(mg)
(mg)
Free
folic
acid
__ (mg)
%
A
BD % A BD % A BD %A
1
125
1
64
16
89
40
72 100 57
1
121
2
56
18
84
40
100 100
58
600 38
1
155
1
73
12
105
40
80. 100
50
600 25
1
136
1
61
14
98
40
88 100
51
Pregnant
(Sedentary)
600 39
1
136
1
69
14
100
40
87
Lactating
(Sedentary)
950 19
1
133
1
69
15
91
80
44 400
15
%
A
Sedentary
600 44
Moderate
work
600 28
Sedentary
work
Moderate
Women
Vitamin
C (mg)
BD % A BD
BD
Man
Niacin
(mg)
100 55
1-3 years
400 24
1
67
1
43
8
52
40
27 30
62
4-6 years
400 30
1
67
1
40
11
59
40
47 40
70
7-9 years
600 23
1
80
1
42
13
62
40
52 60
55
600 27
1
91
1
46
15
66
40
57 70
56
Girls
600 30
1
100
1
72
13
76
40
65 70
57
Boys
600 32
1
108
1
53
16
66
40 65
600 36
1
120
1
58
14
83
40
50 100 45
600 27
1
108
2
56
17
70
40
72 100 48
600 51
1
130
1
75
14
87
40
62 100 47
Children
Boys
10-12
100 43
13-15
Girls
Boys
16-17
Girls
Note: RAD - Recommended Dietary Allowances
Source: Nutritive value of Indian foods, ICMR, 2000.
18
......-------
Karnataka state Nutritlan Pnitr-v
CURRENT SITUATION IN NUTRITION RELATED AREAS
1.
FOOD SECURITY AND AGRICULTURAL PRODUCTION
In spite of attaining food self-sufficiency malnutrition continues to be a
development challenge.
Food
production increases
have
not been
translated into food and nutrition security. This is partly due to high levels
of poverty and the lack of purchasing power among poor households which
reduces the access to food and nutrition. Nutrition security is defined as
the condition when every person has a diet, ’ nutritionally adequate in'
quantity and quality and the food consumed is biologically utilized for a
healthy living.
Karnataka state has to achieve a food production level of, 112.23 lakh
tonnes and 115 lakh tonnes in order to provide food security to its present
population of 5.22 crores, and projected population of 6.5 crores by 200708 respectively. The additional financial resources are made available to
improve dry lands, irrigation resources, reclamation of affected lands, and
arrangements
are
made
to
provide
inputs,
marketing and
other
infrastructure facilities. It is proposed to give more emphasis for increasing
production of dry land crops like Jowar, Ragi, Bajra and minor millets. It
has been suggested to promote the production of nutritionally rich foods
like pulses, oil seeds. etc, with a view to attain self sufficiently. It is
proposed to increase the production level of pulses to 13.23 lakhs tonnes
by 2007-08. It is also proposed to increase the production level of oilseeds
to 29.78 lakhs tonnes by the end of 2007-08. The department is
implementing various thrust programs in order to increase production and
productivity of different crops like Rice, Jowar, Ragi, Wheat and other
millets. In order to help the farmers to control pests and diseases of
agricultural produces during storage, pesticides and equipment like storage
bins and rat-traps are supplied at subsidised rates. Adequate extension
services are also provided to the farmers.
19
Karnataka Sfnfn Nutation Policy
Table:16 Food production in Karnataka during 2001-2002
Foods
\
Production
Cereal & Millets
80.15 (lakh tonnes)
Pulses
7.56 (lakh tonnes)
Oil seeds
10.64 (lakh tonnes)
Milk
4784 (Thousand tonnes)
Egg
20273 (lakhs)
Fish
2.49 (lakh metric tonnes)
Meat
97373 (Thousand tonnes)
J
Source: Estimates ofhigh power committee. Directorate ofAgriculture
2.
HORTICULTURE PROGRAMMES
Mamma Mane - Nanuna Thota
It is a state sector scheme implemented in all the districts of the state
wherein the seedlings of various fruit crops worth of Rs.2000/- are
distributed to small and marginal farmers who can grow these fruit plants
in their kitchen gardens/backyards
A short term training is offered to house wives every month in processing
and preservation of fruits and vegetables and training of 1-5 days is offered
to both farmers and rural women folk on processing and preservation of
various horticulture produce at district and taluk levels itself.
Social Horticulture
Under the programme community orchards with plants of economic
importance will be developed at schools to popularize the economic
importance of horticulture plants including their nutritive value among
school children. Expansion of this programme is also felt necessary even
among rural women folk and rural youth.
Under Nutrition garden scheme, it is envisaged to supply 10 fruit plants
worth of Rs.50/- per beneficiary so that the plants are grown in and
around the dwelling house, as a kitchen garden.
20
Food and Civil Supplies
Livelihood access determines the entitlements and affordability. These
entitlements can be altered through public action and public programmes.
Government policy can increase the entitlements of the people, either by
enhancing incomes or subsidising consumption or both. This would
improve affordability and food access. PDS is one such programme of the
government and effective implementation will have an impact on the
outcomes.
Food grains procured and stocked by the food corporation of India is
distributed to the respective state government through the ministry of food
for distribution through fair price shops. Since, 1987-1988, the PDS has
spread to more households. As per the National Council for Applied
Economics research survey, conducted in 1994, 75 per cent of the
households in Karnataka were using the PDS for some commodity or the
other. A variation has been introduced in 1997 by way of targeted PDS
inorder to remove the element of universality from the system. The ration
card holders are partitioned into families below the poverty line and above
the poverty line. The price, at which the food grains are to be sold to the
families below poverty line, is set at half the economic cost of the
operations to the government. Food grains are sold at economic cost to the
above poverty line families.
Karnataka state food and civil supplies has 20,372 public distribution
systems. The total number of ration cards includes Anthyodaya anna
yojana ration card 4,79,700. Green ration cards 56,83,284 and yellow
ration cards 2,26,407. To all the card holders certain entitlement such as
28 kg of rice, 7 kg of wheat and 3 kg of sugar is given per month at
subsidized rate so that demand in the open market to that extent is
reduced.
All these interventions are made with the assumption that the savings
accrued to the families and institutions due to the availability of food grains
at the subsidized prices, would be used for increasing the consumption of
21
other items which would increase the nutritive value of the total food that
is consumed.
Flow chart indicating different types of ration cards and entitlements.
Health Facilities
The department of Health & Family Welfare Services implements various
National and State Health Programmes of Public Health importance and
also provides comprehensive health care services to the people of the state
through various types of Health and Medical Institutions.
Rural Health Services
In line with the government of India guide lines a three-tier infrastructure
namely sub-centers, primary health centres and community health centres
are established. One Health sub centre for every 5000 population in plain
and for every 3000 population in hilly and tribal areas are established.
Currently 8143 sub centres are working.
22
Jfarn&lAkn !)tnfn i^utrftian PcUIgv
The primary health centre provides basic health services, which includes
curative preventive and promotive health care services. National and State
Health Programmes are also being implemented through the primary
health centres. For eveiy 30,000 population in plain areas and 2000
population in tribal and hilly areas one primary health centre is
established.
At present there are 1^,676 primary health centres in the state. In order to
provide first referral services, community health centres, are established for
one lakh population with minimum of 30 beds providing specialist services
and 249 community health centres are established, so far. The district
hospitals provide treatment to patients and other major teaching hospitals
and specialized hospitals provide specialized services having different
specialties to cater to the needs of the patients of the state.
The national programmes mainly RCH programme helps in achieving the
designed goals in respect of reduction of IMR, MMR, Low birth weight,
babies and birth rate (population control). Control of communicable
diseases, like TB, leprosy, diarrhoeal diseases etc, help in promoting the
health status of the people.
Safe drinking water
Safe drinking water has been accepted as one of the most important basic
services. National norms for the supply of water for domestic purposes aim
at providing at least 55 litres per-capita daily to rural habitation to meet
minimum requirements. This water has also to be safe for drinking and free
from bacterial and chemical contamination.
According to multiple indicator survey-2000 for Karnataka 86% of the rural
house holds and 96% of the urban households have an access for improved
drinking water facility of which 18 per cent of the rural and 49% of the
urban households have drinking water facility within the premises of the
household. However, more than 95 per cent have a facility within 500
metres of the household. Households spent a mean time of 16 minutes per
trip i.e. 18 in rural and 14 minutes in urban areas to catch water.
23
Karnataka Stalo Niitritlnn Policy
OIN GOING NUTRITION INTERVENTIONS IN KARNATAKA
5.
Direct interventions
1. ICDS
ICDS - Adolescent girls programme
2.
Programmes for prevention of micronutrients deficiencies
3.
•
Vitamin
A
prophylaxis
programme
against
vitamin
A
deficiency.
■
*
National Iodine deficiency disorders control programme
Prophylaxis against nutritional Anaemia among mothers and
children.
4.
National Nutrition Mission
5.
Akshara dasoha
6.
Pradhana Mantri Gramodaya Yojana
i>2 1
Indirect interventions
1. Food and Nutrition Board.
2.
Swama Jayanthi Shahari Rozgar Yojana.
3.
Sampurna Grama Swaraj Rozgar Yojana.
4.
Food for work programme.
Direct Intervention
1. Integrated child development services
Integrated child development focuses on essential needs of the children
below 6 years, pregnant women and nursing mothers residing in socially
and economically backward village and urban areas. ICDS provides
supplementary nutrition to children, Pregnant mothers (PM) and Nursing
mothers (NM) for 300 days in a year budget being Rs. 1.50 per day per child
and Rs.3 per day per PM/NM. Children in the age group of 0-3 years
exclusively fed with AREF for all the six days in a week however, children
from 3-6 years consume AREF for 2 days and egg for 1 day and indigenous
recipes (pongal) for tfie remaining four days. On an average supplementary
nutrition programme provides 300-350 calories and 10-15 g protein per
beneficiary per day.
24
Knmntnlta 5 Giro Nirlrtttnn Policy
Growth monitoring
At tlie Anganwadi centres children below 3 years of age are weighed eveiy
month and children between 3-6 years are weighed once in a month.
Growth charts help in detecting growth faltering and assessing nutritional
status. The Angamadi worker identifies the severely malnourished children
(in grade III & IV) and provides special supplementary food.
25
-
Karnatal£a.StatB f^utritlnn Pallr.y
.
Health checkup
Periodical health checkup is being done by the medical officers of the near
by primary health centre once in a quarter and whenever necessary.
nutrition and health education
Basic health and nutrition messages related to child care, infant feeding
practices, utilization of health services, family planning and environmental
sanitation are given to the women through group discussion, house visits
and demonstrations.
2.
Adolescent girls scheme in Karnataka
In the context of the objects of the ICDS programme, the women and child
have to be looked upon as an integral and composite unit. This gap is
represented by the adolescent girls, who bridges the child and the women.
Girls between 11-15 years of age are covered under the scheme wherein
they are given training on home management, health, hygiene, child care
etc., Girls between 15-18 years of age are covered under Balikamandals
where they will be imparted vocational training for six months. All the
adolescent girls enrolled under this scheme are given supplementary
nutrition worth of Rs.2/- per girl per day.
3.
Programmes for prevention of micronutrients deficiencies.
Prophylaxis programme against Vitamin A deficiency
The deficiency of vitamin A can result in the impairment of health, which
can manifest in the form of eye lesions, increase susceptibility to infection
of respiratory system or intestinal tract.
A mega dose of Vitamin A concentrate is administered orally to the children
of 9 months to 3 years. One ml of vitamin A concentrate containing one
lakh I.U. is given to the children of 9 months along with measles
immunization 2 ml of vitamin A concentrate containing 2 lakh I.U. is given
to the children of 1-3 years at six monthly intervals.
26
As a long term strategy, the community is encouraged to take vitamin A
rich foods like green leafy vegetables and carrot and fruits like papaya,
mango and also to grow them through kitchen garden to increase the
consumption of vitamin A rich foods.
National iodine deficiency disorders control programme
The national iodine deficiency disorders control programme was initiated in
order to control severe form of iodine deficiency disorders such as mental
retardation, deafness, mutism, cretinism etc.
In accordance with National policy of universal access to iodised salt, state
also banned the sale of non-iodised salt in the entire state during August
1995 in order to promote universal consumption of iodised salt.
Under this programme intensive educational activities are under-taken to
develop awareness among the community about the consumption of
iodised salt in controlling iodine deficiency.
Prophylaxis against Nutritional anaemia among mothers and children
In order to prevent nutritional anaemia among mothers^ one tablet of iron
and folic acid containing 100 mg elemental iron and 0.5 mg of folic acid is
given daily to pregnant women for 100 days while those with anaemia are
given two tablets per day.
For children of 1-5 years one tablet containing 20 mg of elemental iron and
0.1 mg of folic acid is given to prevent dietary deficiency. For smaller
children who cannot swallow tablets, limited quantity of liquid preparations
are also being supplied. The daily dose is 2 ml which is equivalent to one
tablet.
4.
National Nutrition Mission
The objective of the mission are to reduce macro and micro malnutrition
and also the chronic energy deficiency. The project is operating in Gulbarga
and Kolar district. In the project undernourished adolescent girls and
27
pregnant and lactating mothers in the community are weighed four times
in a year and their nutritional status monitored. The undernourished
women during pregnancy and lactation gets 6 kgs of food grains from PDS
shop free of cost for three consecutive months. In addition nutrition
education is given to women and girls.
5.
Akshara dasoha
The main objective of serving hot cooked mid day meal is to improve
enrolment and attendance, to reduce dropout rate and further, to improve
the nutritional status of the children.
6.
Pradhan Man tri Gramodaya Yojana (PMGY)
PMGY is a new initiative which aims at achieving the objective of
sustainable human development at the village level. The yojana specially
provide for nutritional supplementary feeding cost to children from 6
months - 3 years of age and to combat malnutrition.
Indirect Intervention
1. Food and Hutritlon board
The government of India’s Food and Nutrition Board, organizes awareness
programmes on healthy nutritional practices, using locally available
inexpensive foods. These IEC activities target the vulnerable segments of
the community. Training in domestic methods of fruit and vegetable
preservation and nutrition education is imparted to housewives, adolescent
girls and self help group members. Technical guidance on manufacture of
any preserved fruits and vegetable and instant infant food mixes is
extended if taken up as income generating schemes.
The activities of the Board are limited to areas around Bangalore and
Mangalore city only, where the two units are stationed. Since the
educational component plays a veiy vital role in reducing the extent of
malnutrition, there is a need to set up more such units to cover the
northern districts.
28
Karnataka State Nutrition Policy
6.
CAUSES OF MALNUTRITION
Figure: 6 clearly depicts spectrum of causes of malnutrition. Holistic
analysis of nutritional problem in our country can be conceptualized into
three major causes namely basic and underlying causes which are
intricately related. In requisition of these causes national nutritional policy
advocates a comprehensive integrated intersectoral strategies for alleviating
the multifaceted problem of malnutrition to achieve optimum nutrition for
all with a focus on women and children.
A Spectrum of causes of malnutrition
Fig: 9
29
,Kiunataka.S tatn Nutrition Policy
7.
KARNATAKA STATE NUTRITION POLICY
Karnataka state Nutrition policy emphasises the need for reduction of
malnutrition of all types including micronutrient malnutrition among
children, adolescent girls and women of child bearing age.
Since nutrition is a multi-sectoral issue, it needs to be talked at various
levels, both through direct short-term nutrition intervention especially for
vulnerable groups, as well as through other long-term policy intervention.
THRUST AREAS IN NUTRITION POLICY
1. Chronic Energy Deficiency among children.
2.
Tribal Nutrition.
3.
Hidden hunger caused by micronutrient deficiencies.
4.
Prioritization of resource according to nutritional problems of the
particular geographical area.
5.
Maternal and foetal malnutrition.
.----- 6. Infant feeding practices: Emphasis on timely supplementary
feeding.
7.
Enhancing purchasing power through sustainable livelihood for
food security.
8.
9.
Horticulture intervention to combat micronutrient malnutrition.
—5 —
<>■
Effective coverage of Public Distribution System.
10.Better linkages with RCH components.
11.
Enrolment of children below 2 years of age to ICDS.
12.Focus on Adolescent girls in all the ongoing programmes.
13.IEC activities: Strengthening of IEC activities in the on going
nutrition programmes.
14.Ensuring participation of NGO’s in Nutrition programmes.
15.
Intersectoral Coordination.
16.
Essential periodical monitoring.
.
■ —
------------------
--------
8.
. --------------- - -----------
Karnataka Stain Nutrition Policy
PLAN OF ACTION
Short term strategies
•
The ICDS programme has made an impact in reducing severe forms of
malnutrition. However, a major portion of children are suffering from
moderate and mild malnutrition. Since, the peak prevalence is at the
age of 2 years, it is important that the programme, shifts its emphasis
in providing supplementary nutrition to children below 2 years of age.
■
The programme of adolescent girls in the ICDS needs to be intensified
not only for supplementary feeding but also for development of home
based skills, non-formal education particularly nutrition and health
education. All adolescent girls of economically poor section should be
included in the ICDS in phased manner.
*
Emphasis is required to cover all children, adolescent girls and women
of child bearing age under ICDS in tribal areas.
■
Growth monitoring which is a tool for educating the mothers needs to
be intensified.
■
Strengthening of IEC activities in ICDS programme through developing
educational material with regard to exclusive breast feeding, timely and
proper weaning food for supplementary feeding.
■
To control and prevent micronutrient malnutrition the
existing
prophylactic programme for Vitamin A deficiency and anaemia should
include all children below 3 years both in urban and rural areas on a
continuous basis.
■
Monitoring of prophylactic programmes should be given higher priority.
•
Continuing of Akshara dasoha programme for improving attendance at
school and also to reduce dropout rate. Further, the programmes helps
to improve the nutritional status of children in school age.
■
Distribution of iodized salt in endemic areas of the state.
■
Fortification of salt with iron along with iodine needs to be taken up.
■
Providing iron and folic acid tablets in medicine kit distributed to
Anganwadi centres.
31
famiak* sutr Niiuttfan PvHn
Long term strategies
To overcome malnutrition an enabling environment will have to be created
for household by ensuring food security, access to basic health services
and adequate care for women and children.
In the light of economic reforms which have pressurized the poor, the
action of the state would be on the following lines.
■
Strive for nutrition security rather than just food security.
•
Development of nutrient dense foods through research.
■
Activities towards empowerment of women should be taken up besides
creating employment opportunities.
•
Strengthening of women self help groups.
•
More emphasis on universal immunization in tribal and remote areas.
■
Improved prenatal and post natal care should be made accessible to all
women.
■
Small family norms and adequate spacing should be encouraged so that
the food available in the family will be sufficient for providing adequacy
of nutrients to all members
■
■
Assured access to adequate safe drinking water to all habitants.
Sanitation and hygienic conditions in anganwadi centres should be
addressed.
■
Horticulture intervention to increase production of horticulture crops to
combat micro-nutrient malnutrition.
■
Promotion of nutrition gardens at aganwadi centres wherever possible.
9.
MODALITIES FOR IMPLEMENTING THE NUTRITION POLICY
The state nutrition policy can be effectively implemented by convergence of
service, better coordination of activities by different sectors. For this
purpose various sectors be involved and intrasectoral linkage established at
various levels i.e. state, district and sub district.
At the state level
The coordination committee headed by chief secretary is already in
existence of reviewing the state plan of action for the child in the state. The
32
■
----------------------- -
■
------
■
- .
Karnalaka Stain Nutrition Policy
same committee should also coordinate and monitor the implementation of
state nutrition policy.
A state level task force will be constituted consisting of representatives from
government, NGOs, experts from professional bodies and international
agencies. The task force will provide technical guidance and managerial
support for implementing the state nutrition policy and ensure that the
implementation at the district and taluk level is directed the original
objectives of the policy. The task force would also suggest measures in
programme planning, training, implementation, monitoring and evaluation.
The task force will also be responsible for obtaining a continuous feed back
of the implementation at the state level.
At the district level
The nodal agency will be the women and child development department
and ensure convergence of available community services from different
department like health, education, rural development and ICDS etc.,
support of NGOs in the field of nutrition would also be encouraged.
At the Sub-District level
At this level the focus will be on the implementation of nutrition related
interventions. The front line worker of various departments including
Anganwadi workers and NGOs will have to identify the vulnerable and
unreached families for the various programmes and enable women as well
as other family members to participate in the activities.
IO.
NATIONAL NUTRITION SURVEILLANCE SYSTEM (NSS)
To achieve HEALTH FOR ALL BY 2000 AD, promotion of nutritional well
being was considered an essential element. The GOI had formulated the
National Nutrition Policy (NNP) in 1993 and as a part of its policy the NSS
(National Nutrition Surveillance System) has been established to provide
early warning about nutrition problems for initiating prompt action and to
ensure optimal nutrition to' the “at risk” groups. With UNICEF support,
33
NIN, Hyderabad has been using the 1CDS infrastructure to collect
information which will be useful in decentralized micro-planning. The
essence of the surveillance is triple A cycle of ASSESSMENT, ANALYSIS
and ACTION and the training module developed and presently in use has
been found to be extremely useful.
Advantages of NSS
•
Entire population, especially the vulnerable groups, will be under
■
It provides information on various process and impact indicators at
surveillance.
various levels at quarterly intervals for initiating appropriate action. -
■
It enables preparation of action plans on nutrition for implementation
*
"At risk” groups and areas i.e. children less than 3 years, SC and ST
by the district officials.
population can be identified.
*
It can provide timely warning signals about the impending nutritional
problems.
■
It will help in better programme management as it helps to identify
workers, who are performing poorly.
•
Intervention programmers can be evaluated on a continuous basis by
assessing the extent of achievement against the goals.
■
Growth monitoring at quarterly intervals enables early diagnosis of
children with growth faltering and prompt initiation of remedial
measures.
■
It enables “mapping” of the extent of under nutrition at sector / project
/ district levels. Such an information will enable demarcation of most
nutritionally vulnerable “villages / sectors / projects".
■
It will assist in enhancing the interaction between departments
•
It confers accountability at all levels and enables better management of
concerning maternal and child health and development.
limited resources available by diverting them to needy areas.
This programme is under implementation all over Karnataka.
vorninuhiiy Heaith Cfeii
t-rom:
umesh kapii" <kapHumesh(g'notrnaii.com>
Sent:
Monday, June 21, 2004 5:01 PM
Subject:
National workshop on IDA.VAD and !DD,AI! India Institute iof Medical Sciences,
Dear Colleague.
Nutrition disorders due to deficiencies of Vitamin A, Iron and Iodine are major public health
PxOuieiliS ill Oui COUiltry. Faculty members arid xteSeorch Scientists rTviu MediCal and Home oCieliCe
Colleges, National and State Level institutions have been undertaking research surveys to assess the
magnitude of Vitamin A Deficiency Disorders (TDD). Iron Deficiency Anemia (IDA) in the communities to
strengthen the various intervention programmes.
In a recent review of research studies undertaking/' published during last 50 years, in the field of
Vitamin A. Iron and Iodine deficiency disorders revealed that the indicators utilized for assessment of VAD,
IDA 2nd TOD me not
and ?.t times scientificuHv not correct.
Iu view of above, Depaiimeui of Human Nutiiiion, Au India Institute of Medical Sciences m
collaboration with Indian Public Health Association, Indian Association of Social Medicine, Nutrition
Society of India (Delhi Chapter) and Indian Academy of Pediatrics (Nutrition Chanter) is organizing a
’ National Workshop on Nlcthodologics for Assessment of Vitamin A Deficiency’, Iron Deficiency’ Anemia
and iodine Deficiency Disorders” as per the following schedule:
.
uaie
Time
;
,,lh.io .u,-lh oepiemoer,
r> , <
ij
zuu*t
: 10:00 AM to 5:00 PM
Venue : Jawaharlal Nehru Aiidi<<?rium, A.TljMS, New Delhi
Objectives of the workshop:
jcq
tlie
ctr» MvOut fiip. current stetus of
D^fictsnc*r IX»TXTX^
Iron Deficiency Anemia (IDA) and Iodine Deficiency Disorders (IDD) and the national
programmes for their prevention and Control.
To updute the pnrfir»nlprc 2hout the VZHO glohsl indicators for
of ADD IDA 2nd TDD
13“ to 15“ September, 2004
i)
Faculty members, scientists, post graduate students of Medical and Home Science Colleges
P-eseerch Scientists fiom hletionel end State Level Institutes
in) Healdl Piauueis, Adiumisuatuis, riogiuuune Managers uoul state governments
iv) Scientists and Nutritionists from International, Bilateral and Voluntary organizations
The participants would be updated about the magnitude of micronutrient deficiency i.c. Vitamin A
Deficiency Disorders Iron Deficiency .Anomi?! and Iodine Deficiency Disorders nnd rtreto^po- for their
prevention and control. They will also be updated about recent methodologies for assessment of magnitude
of micronutrient by utilizing global indicators recommended by WHO.
It is expec!ed that this national workshop would strengthen the research methodological skills of
scientists working m the lield vl Vitamin A Deliciency Disorders. The Workshop woulu he>p me scientists
in generating data by utilizing scientifically valid indicators which would facilitate in inter-state and
international comparisons about the magnitude of Vitamin A Deficiency Disorders, Iron Deficiency Anemia
and iodine Deficiency Disorders.
On behalf of the Organizing Committee, 1 invite you to participate in this national workshop.
miring forward to meeting you,
6/22/04
6/22/04
Page 2 of2
Your sincere!’.’.
U m e—s Az
Dr. Umesh Kapii MD, DNB, FAMS .FIPHA.FIAPSM
Professor Public Health Nutrition
Department of Human Nutrition
AU India Institute of Medical Sciences,
New Delhi 110 025, INDIA
iei No: (On) 91-11- 26593383 ; (R) 91-11-26195105
Mobile:. 98106093-10
Fax : 91-11-26588641,91-11-26588663
email kaDilumestiCThotmail.com
6/22/04
Page 1 of 4
From:
Sent:
Subject:
"kapil umesh" <umeshkapil@yahoo.com>
<shashi_p_gupta@hotrriail.com>; <mina@hsph.harvard.edu >; <ravifly@netscape.net>;
<taw256@yahoo.com >; <suniigomber@hotmail.com >; <nfi@ren02.nic.in>;
<keroo@bgl.vsni.net.in >; <sdgupta@iihmr.org>; <gvsmurthy2000@yahoo.com>;
<HaiderR@WHOSEA.ORG>; <jqureshi@brain.net.pk>; <mrsnandini@rediffmail.com>;
<shoba72@yahoo.com>; <itispreeti@hotmail.com>; <priyalipathak@hotmail.com>;
<vanisethi777@yahoo.com>; <hpssachdev@hotmail.com>; <chaudhry_kc@yahoo.com>;
<gstoteja@yahoo.com>; <s_padam@hotmail.com >; <vijaiksri@yahoo.com>;
<indiracal@hotmail.com>; <jabnazj@yahoo.com>; <izzuhat@omantel.netorn>;
<jamil@icddrb.org>; <umeshkapil@yahoo.com>; <drjcdas@rediffmaii.com>;
<jinat@hkidhaka.org>; <jiten_ksingn@yahoo.com>; <jpgupta36@sify.com >;
<wdnipccd@ndf.vsnl.net.in>: <kailashbansal@hotmail.com>; <kn_aniurtupil@yahoo.com>;
<deekshakapur@hotmail.com>; <kdesai@ctisinc.com>; <crsoman@vsnl.com>;
<khanums@who.ch>; <kiranbains68@hotmail.com >; <kna_ped@yahoo.com>;
<Lalita.Bhattachaqee@fao.org>; <madangcdbcle@yahoo.co.in>; <monusvm@yahoo.com>;
<msaeed_addu@yahoo.com>; <yomalhur@unicef.org >, <iandon_monica@hotmail.com >;
<mriduiabarooan@yahoo.co.in>; <chad@cmcvellore.ac.in>; <nemat@akfindia.org>;
<drrangan@rediffmaii.com>; <viji452@yahoo.com>; <dr_sivakumarb@yahoo.com>;
<gnvbrahmam@yahoo.com>; <paul_cn@rediffmail.com>; <cessiam@tikal.net.gt>;
<pannachaudhury@hotpop.com>; <jsthakurjn@yahoo.co.in>; <rajeshkum@sancharnet.in >;
<aggak63@glide.net.in>; <rsp.rao@kmc.manipal.edu>; <drpiyush@satyam.net.in>;
<aroraprabha@hotmail.com>; <prema_ramachandran@yahoo.com>; <cwch@neksus.com>;
<lakshmi@aravind.org>; <drsanwar@sanchamet.in>; <raisachar@rediffmail.com>;
<drrajat_prakash@yahoo.co.in>; <sandip89@hotmai!.com>; <rshah@ctisinc.com>;
<sarkars@un.org>; <psethuraman@idrc.org. in>; <sghcsh@del3.vsnl.net. in>;
<cancer@datainfosys.net>; <svir@unicef.org>; <shinjini_bhatnagar@rediffmai!.com>;
<siddharth@ehpindia.org >; <subbuiakshmi_g@hotmaiLcom>; <s_mukh22@rediffmail.com>;
<sudhanshmalhotra@hotmail.com>; <msswami@mssrf.res.in>; <drtcgupta@yahoo.co.in>;
<aiumni@vsnl.com>; <psgaidsinfo@satvam.net.in >; <vinods51@hotmaii.com >
Monday, October 18, 2004 10:03 AM
Wonder Candies for Indian poor children and mothers
Dear Colleague
The below mentioned letter and Press release is self explanatory.
International Voluntary organisation wants that"Wonder Candies" should be given to r our poor
children and mothers.
I look forward for comments from you
Prof Umesh Kapil
AllMS
New Delhi
Dr. Luc
Regional Director,
Micronutrient Initiative,
208. Jor Bagh. New Delhi
India 110003
Dear Dr. Luc,
I read the News item entitled □School becomes sweeter with candiesD published in Times of,India„
Page 2 of 4
Delhi Edition dated September 28th on Page No. 11 with great interest (The copy of the article is
reproduced below).
MI representative has mentioned in the above News article that the fortified candies developed and
distributed by Ml are the best and most effective option available for providing micronutrients to
children and mothers.
An important issue which need to be answered is , do we have adequate data on effectiveness of
these fortified candies, under the public health intervention conditions, to prove that there was a
reduction in prevalence of anemia, improvement in growth, reduction in prevalence night blindness
amongst women and children. I would be grateful if the published data can be shared so that I can
update myself on this issue.
It will be also interesting to know the exact cost of these fortified candies produced. I am sure that
while calculating the cost the following aspect would be considered
i.)
ii)
iii)
iv)
v)
vi.
vii.
viii.
ix.
x.
Capital cost of the machinery and equipments
Cost of construction / hiring the infrastructure for placement and use of
machinery and equipments
Cost of raw material used in preparation of candies
Cost of storage of raw material
Cost of Manpower employed for production
Cost of training of functionaries
Cost of distribution of candies
Cost of monitoring of distribution
Cost of depreciation of machinery and equipments
Wastage and transmission losses
India is a developing country, where there is a strong need of a judicious utilization of meager
resources available for underprivileged the mothers and children.
Locking forward to an early response
With Kind regards
Umesh Kapil
School becomes sweeter with
candies
Tuesday, September 28, 2004
New Delhi
The Times of India,
10/20/2004
Page 3 of 4
By Shivani Singh/TNN
New Delhi: This toffee has made school going a more appetizing proposition. Packed with essential
micronutrients, fortified candies have pushed up the enrolment rate to almost 90% at government
run kindergartens or Aganwadi centres in certain districts of West Bengal, Bihar, Gujarat and Andhra
Pradesh.
This wonder toffee is doing brisk business where the govcmmcntDs much-discussed mid-day meal
scheme for primary students, is only dawdling.
It has. however, helped another sarkari scheme, the Integrated Child Development Scheme; pick up
momentum in some parts of the country.
Through out by a Canadian NGO, Micronutrient Initiative (MI), which is also funding the project, these
•3fortified candies are being distributed free of cost to young children (3-6 years) and pregnant and
lactating mothers under the ICDS.
In West Bengal, where the project started two years back, enrolment has gone up to 90-95%, MIDs
national programme manager, Saraswati Bulusu, claims.
□These candies are being given along with the regular nutritious food under the ICDS. We thought of
several products, sandesh and rosogolla, that could be fortified to give supplement nutrition to children
and mothers. Hard-boiled centre-filled candies seemed the best and most cost-effective option,
Buiusu Added.
There arc fortified edible products like cornflakes and ana available in the market. But not within the
reach of economically underprivileged. DFortified candies provide iron and vitamin supplements to a
large number of children and mothers suffering from anaemia, decreased growth and night blindness,
Bulusu said.
About 50% of pregnant women, 65-70% of adolescent girls and children suffer from iron deficiency.
Fortified food candies, atta and iodised salt, could be an effective way to fight it, Bulusu calims.
Impressed by its success in West Bengal, the state governments of Andhra Pradesh, Bihar and
Gujarat have invited MI to run similar project at their Aa°anwadi.
Dr. Umcsh Kapil MD, DNB, FAMS ,FIPIIA,FIAPSM
Professor Public Health Nutrition
Department of Human Nutrition
All India Institute of Medical Sciences,
10/20/2004
Page 4 of 4
New Delhi 110 029, INDIA
Tel No: (Off) 91-11- 26593383 ; (R) 91-11-26195105
Mobile:. 9810609340
rax : 91-11-26588641, 91-11-26588663 kapiiumeshceiihutmaii.tum
Page 1 of 1
Nev- M
CHC
From:
To:
Cc:
Sent:
Attach:
Subject:
"chin123" <info@chinindia.org>
<shrc@hathway.com>; <skcv@skcv.com>; <sochara@blr.vsnl.net.in>;
<sonalzaveri@vsnl.com>; <source@ich.ucl.ac.uk>; <ssrawat@vsnl.com>;
<sujata55@hotmail.com>; <talc@talcuk.org>; <terinakeene@yahoo.com>;
<Timgrandage@vsnl.net>; <t-martineau@dfid.gov.uk>; <training@fundraising-india.org>;
<tstaurt@unicef.org>; <ujumaniad1@sancharnet.in >
<unaids@unaids.org>; <upadhyam@who.org>; <vinayakan@pciindia.org>;
<webinfo@rockfound.org>
Thursday, November 11, 2004 4;36 PM
lssue-8.pdf
CHIN News-8
November 11, 2004
Dear friends,
Festive greetings from the Communication for Health India Network (CHIN) Secretariat, CHETNA!
41
Realizing the critical need for exchanging information with like minded organizations, CHIN strives
to share information, innovative approaches on health and development of the vulnerable groups in
India including the partner’s efforts. To enable this to happen, the network publishes CHIN News
(e-newsletter) thrice in a year focusing on different themes. A total of seven issues have been
developed and disseminated so far. We are pleased to share with you the much awaited 8th issue of
CHIN News on “Nutrition and Health” particularly child health.
Please share the newsletter with your partners and let us know whether you would like to continue
receiving it. In case of no response from your side, your address would be deleted from the mailing
list.
We welcome your valuable suggestions on this issue of newsletter.
Happy reading
z •
’• 3
W
With warm personal regards,
Ms.Chitra Iyer
CHIN Coordinator
For CHIN Secretariat, CHETNA
Attachment: (PDF)
Let’s celebrate the birth of a girl child
16-Nov-04
Communication for Health India Network
CHIN NEWS
May to August 2004 - Issue 8
Nutrition and Health
Nutrition plays a critical role in the
physical, mental and emotional
developmentof human beings. In most
parts of the world (particularly in
developing countries), inequity,
poverty, underdevelopment, unequal
distribution and poor access tofood and
health care leads to severe
impoverishment.
Nearly 30%of humanity, especially
those in developing countries infants, children, adolescents,
adultsand olderpersons bearthis
triple burden.
Dr.Gro Harlem Burndliand, Director General at the
World Economic Forum 2000
Nutrition and Child health
The nutrition needs vary according to
the age group, status and work pattern.
Hence it is important that health and
developmentconcerns are addressed
during each stage of life adopting a
comprehensiveapproach.
India has ratified the UNCRC and the
Constitution of India guarantees equal
rights to all citizens. However, a large
partof the children’s population in India
is not able to meet its required nutritional
needsdue to various reasons.
Whatailsourchildren?
• Poverty, unequal distribution of
resources, lack of food security,
continued discrimination in food and
health care during the growing period
of infancy, early childhood and
adolescence affect the physical and
psychological development during
later years of life.
• Povertyleadstoinadequateintakeof
nutritious food, making them more
disease prone.
• I nadequate or inappropriate food leads
tostuntedgrowth and prematuredeath.
• Nutrientdeficientdietprovokeshealth
problems; malnutrition increases
susceptibility to diseases such as
nutritional anaemia.
• Genderdiscrimination, lowliteracy
rates and lack of awareness affecting
the nutritional status of the children
especially girls.
• Delay in initiation of breastfeeding,
myths related to colostrum feeding,
initiation of feeds otherthan breast
milk during the first few hours after
birth, bottle-feeding and delay in
inflation of complimentary foods; and
faulty feeding during and after illness.
• Unsatisfactory conditionsof hygiene,
causing worm infestation, diarrhoea,
environmental sanitation and limited
coverage of immunization against
communicable diseases further
aggravates thegrave situation.
• Irrational beliefs and prejudices about
nourishing foods and ignorance about
how to make nutritional use of locally
available foods results in intake of
inappropriate food.
1
• Lacunae in the existing programmes,
policies and poor implementation of
the programmes, lack of availability
and accessibility to timelyquality
preventive health care services to
motherand children dueto which the
disease prolongs.
• Continuousstretchofpoverty,
hunger, illness and inaccessibility
can result in death.
All these factors impact on the state
of the health of India's children and
would continue to impact unless the
multiple determinants of health are
addressed.
There is an urgent need for holistic
and sustainable health interventions,
which provide access to quality and
affordable health care through well
planned, gender sensitive,
comprehensive and integrated
policies and programmes that provide
care for millions of children
irrespective of any bias. Let us join
hands for ensuring quality health for
all children. We invite parents,
community, programme planners and
policy makers to join us in upholding
the rights of the children.
CHIN Secretariat, CHETNA
November 2004
Mission
CHIN aims to increase access to
appropriate information and to
influence policies and practices
for improving the health and well
being of vulnerable groups.
Children’s righttofood & nutrition
As proclaimed by the UN Convention on
the Rights of Children (UNCRC1989),
childhood is a protected niche in the
social environment, a special time and
place in the human life cycle. All children
have a right to be adequately nourished
to attain and maintain optimum health
and development. Children are the worst
sufferers of increased commercialization,
globalisation, environmental degradation
and gender discrimination, the struggle
for survival starts even before their birth.
If they do survive, most of them are
underweight with widespread chronic
malnutrition particularly in developing
countries.
Nutrition rights of children
• Have access to adequate food and
nutrition to ensure healthy
development from birth onwards.
• The Convention on the Rights of the
Child states that it is the right of the
children to enjoy the highest attainable
standard of health, that governments
shall ensure food security and provision
of nutritious food, and that parents and
children have information about nutrition
• Have the right to survive especially girl
child. Exclusive and continued
breastfeeding to reduce infant
mortality and morbidity.
• Have access to quality and functional
health services to address children's
health need specifically.
• Increased intensification of child survival
programmes, protection from social and
physical environment, communicable
diseases and diseases like HIV/AIDS.
• Ensuring basic rights to childhood
While child health is an urgent need, in
developing countries, it is essentially linked
to the health and nutrition of adolescents
and women’s health. Developing countries
like India, Nepal, Bangladesh and Pakistan
contribute significantly to global maternal
and child deaths. Women and children are
the worst sufferers from the ravages of
various forms of malnutrition because of
their increased nutritional needs.
Equitable food distribution both within
the community as well as the household
and better nutritional awareness are
required to alleviate the situation.
Nutrition matters
throughout the life of a
child
Cycle of Malnutrition
Ensuring adequate nutrition for
children (particularly girl child) from
early age (0-3 years) and
throughout their life will help prevent
low birth weight in new born and
break the intergenerational cycle of
malnutrition.
Main consequences of malnutrition throughout the
course of life
Common nutritional disorders
Main consequences
Pregnant and lactating women
Protein energy malnutrition
Insufficient weight gain in pregnancy,
(PEM), Iodine deficiency
maternal anaemia, maternal mortality,
disorders (IDD), Vitamin A
increased risk of infection, night blindness,
Deficiency (VAD), Iron deficiency
low-birth weight/high risk death rate of
Anaemia (IDA), Folate deficiency
fetus
Embryo/fetus
Intrauterine growth retardation
Low birth weight
IDD
Brain damage
Neural tube defects, Still births
Folate deficiency
Neonate
Low birth weight
Growth retardation
IDD
Development retardation, brain damage
and early anaemia
Infant and young child
PEM
Continuing malnutrition, development retardation
IDD
Increased risk of infection
VAD
High risk of death
IDA
Goitre, Blindness, Anaemia
Adolescent
PEM, IDD, IDA
Delayed spurt
Folate deficiency
Stunted height
Calcium deficiency
Delayed/retarted intellectual development
Goitre, Blindness, Anaemia
Adult
PEM, IDA
Thin
Obesity
Lethargy
Diet related diseases
Obesity, Heart disease, Diabetes,
Cancer, Hypertension/stroke, anaemia
Older persons
PEM, IDA
Obesity
Spine, hip fractures, accidents
Obesity
Osteoporosis
Heart diseases
Diet-related diseases
Diabetes, Cancer
Source: Nutrition for Health and Development, WHO
Acronyms
IDA: Iron deficiency anaemia
PEM: Protein energy malnutrition
IDD: Iodine deficiency disorders
VAD: Vitamin A Deficiency
Nurturing nutritional well-being and health is a life long process, with each
phase affecting the next. Hence every concerned citizen should be equipped
to take appropriate timely measures for healthy living.
2
Global Scenario
Nutrition Status in India
Malnutrition is associated with about half of all child deaths
worldwide. Malnourished children have lowered resistance
to infection; they are more likely to die from common
childhood ailments like diarrhoeal diseases and respiratory
infections; and of those who survive, frequent illness saps
their nutritional status, locking them into a vicious cycle of
recurring sickness, faltering growth and diminished learning
ability.
India accounts for the largest number of undernourished
children in the world. Survival and health of children is
influenced by nutrients available not only to them but also
to their mothers.
Mr.Pedro Medrano, Country Director, WFP at the Regional
Consultation on Mission 2007: Initiatives for Hunger Free
India quoted that inspite of having largest surplus of food in
the world, largest food protection systems such as
Integrated Child Development Services (ICDS), Public
Distribution System (PDS), Food for Work, Mid Day Meal
(MDM) programme, India still has largest number of
malnourished children/people in the world - a major risk
limiting the development potential and active learning
capacity of India’s children.
Under weight prevalence declined from 32 % to 28% in
developing countries over the past decade with the most
remarkable progress in East Asia and Pacific, but the high
levels of under nutrition in children and women in South
Asia and Sub-Saharan Africa pose a major challenge for
child survival and development.
Every fourth child in India is born with Low Birth
Weight and almost every second child below the
age of three years is malnourished
Source: UNICEF Mater Plan of Operations 2003-2007
Major nutrition problems of India:
Chronic hunger, Hidden hunger (micronutrient deficiency)
resulting in - Protein Energy Malnutrition (PEM), Iron
deficiency- Nutritional Anaemia, Iodine deficiency disorder,
Vitamin ‘A Deficiency, diseases of poverty, Transient
hunger caused due to seasonal dimensions, emergencies
such as natural calamities, market distortion, urbanization
are some of the problems related to malnutrition in India.
Poor care practices of young children; insufficient maternal
nutrition, inadequate hygiene, nurturing and psychosocial
care, inappropriate infant and young child feeding
practices, and home health practices add to the existing
food security.
Any progress could be made only when provision of basic
services is combined with support for initiatives that inform
and empower communities and families (particularly
women) to ensure adequate nutrient intake and prevent
infectious diseases.
3
Existing Nutritional Policies/Programmes in India
4.
To deal with the issue of the malnutrition, various efforts
are being made by GOs/NGOs. Some of the existing
policies/programmes are:
1.
National Nutrition Policy, 1993
In view of the crucial role of nutrition in development as
well as the complexity of the problem, the Government
of India brought in force the National Nutrition Policy which
serves as a guideline for administering and monitoring the
effectiveness of the existing nutrition programmes.
2.
Integrated Child Development Services
The Integrated Child Development Services (ICDS)
scheme introduced by the Government of India (GOI) is
the largest nutrition programme for children under six
years of age, and women who are pregnant and breast
feeding. Launched in 1975, the services provided are
supplementary nutrition, immunization, health check-up,
referral services, non-formal pre-school education and
nutrition and health education. It is an appropriate
vehicle to combat micronutrient malnutrition, however
the programme presently covers only 50% of children of
which children below three years are excluded.
3.
Reproductive and Child Health
In order to fulfill commitments made in the International
Conference on Population and Development (ICPD),
Cairo, 1994, the Government of India launched the
Reproductive and Child Health Programme in 1997 which
incorporates components of Child Survival and Safe
Motherhood and also includes components, related to
Reproductive Tract Infections/Sexually Transmitted
Diseases, STD/HIV/AIDS, infertility and abortion. Under
this Anaemia prophylaxis programme, all pregnant
women, lactating mothers are given minimum 100 tablets
of Iron Folic Acid and universalisation of Vitamin A to all
children of 0-5 years to reduce deficiency of Vitamin A,
iron and folic acid and iodine among vulnerable groups
Goitre
5.
Control Programme
Initiated in the year 1962 to identify goiter endemic
regions and to assess the impact of goiter control
measures. The availability and production of iodized
salt, strengthening of administrative machinery
controlling the entry of non-iodized salt in the endemic
regions have been recommended as measures to
improve the implementation of the programme.
Mid Day Meal Programme
6.
Initiated in 1956 by Madras State, the programme was
then sponsored by central government from 1962-63 in
all states to improve the nutritional status of the school
children and to attract children to enroll themselves into
school and to encourage regular attendance by
providing supplementary nutrition, the programme
provides one meal to the children attending the
school.
Food and Nutrition Board
Reconstituted in 1990, the board advises government,
coordinates and reviews the activities in regard to food
and nutrition extension/education, development,
production and popularization of nutritious foods and
beverages, measures required to combat deficiency
diseases and conservation and efficient utilization as
well as augmentation of food resources by way of food
preservation and processing.
Priorities for action
• Implementation of proper land use policy to prevent
diversification of agriculture land for commercial
purpose.
Given the complexity of the problem, the challenge is to
generate requisite political will, develop realistic policies
and taking concerted action nationally and internationally.
Some of the priority actions for policymakers/programme
planners/NGOs/parents/family/communities could be:
• Effective implementation of land reforms measures to
reduce the vulnerability of landless labour.
Policy & Planning
• Expand nutritional intervention net through Integrated
Child Development Services (ICDS) to reach out to all
children in the 0-6 age group
• Countries/States should develop their specific plans of
action on Infant and Young Child Feeding targeting most
needy states, communities and children.
• Ensure equitable food distribution through expansion of
public distribution system - access to the essential food
articles
• Introduction of appropriate incentives, pricing and
taxation policies to meet the national nutritional needs of
adolescents, women and children
• Involve the Community through their local self
governance (Panchayat) or where Panchayat do not
exist, through beneficiary committees in the
management of nutrition programmes and
interventions
• Introduction of mobile crdches to guarantee the women
and child their nutritional and health rights
4
Enhancing awareness and mobilizing support (GO/
NGOs)
Monitoring and Evaluation
• Establish a mechanism for monitoring and ensure
periodic monitoring of the nutritional status of children,
adolescent girls and pregnant and lactating mothers
below the poverty line - monitoring of various nutritional
programmes
• Create awareness about importance of nutrition and
health, balance diet, low cost nutrition, National Nutrition
Policy through media (electronic, folk and print) to
combat malnutrition especially among girls, adolescent
girls and women in the reproductive age group.
Efforts
• Strengthen the National Literacy Mission to educate and
empower women to have greater roles in decision
making, particularly those relating to nutrition and
feeding practices.
Global level - Millennium Development Goals
The Millennium Development Goals (MDGs) commit the
international community to a comprehensive vision of
development - one that places human development as the
centrepiece of social and economic progress.
• Sensitize and build capacities of local self governments
(panchayat) and establish linkages to ensure
convergence of programmes and services for the health
and development of community.
Millenium Development Goals
• Promote gender equality
• Eradicate extreme poverty and thereby reduce child
mortality
• Popularize low cost nutritious food from indigenous and
locally available raw material
• Promote kitchen gardens, food preservation, preparation
of weaning food processing units through women's self
help groups both at home level as well as at the
community
National level: India as a party to decisions is
organizing a series of round table conferences to have a
dialogue with experts from govemment/NGOs and other
international organisations to achieve the overall health and
development of the nation. One of the major aims is to
reduce the under 5 mortality rate by two thirds by 2015.
• Generation of effective demand at the level of the
community for all services relating to nutrition.
• Organize discussions with all stakeholders (teachers,
pregnant women, lactating women, husbands, youths,
family members, child care workers, health workers and
field based functionaries) to influence attitudes and
public opinion on nutrition practices.
Local level: Striving for achieving the Millenium
Development goals of India, the major highlight during May
to August 2004 was organisation of a series of
consultations and seminars on strengthening Early
Childhood Development (ECD) and Integrated Child
Development Services (ICDS) by Government and the Civil
Society Organisations to formulate recommendations for
holistic development of children. The CHIN partners
observed Nutrition Week (September 1-7) by conducting
and participating in various activities through their field
partners.
• Encourage role of male members in the family and
community to take care of the nutritional needs of girls,
adolescents and women in particular.
Priority areas for Programme Improvement
• Increase the purchasing power of the poor, improve the
provision of basic services to the poor and to devise a
security system through which the most vulnerable
sections of the poor can be protected.
National Partners’ Meeting on
Breastfeeding
• Fortification of essential foods.
Breastfeeding (BF) is the single most effective intervention
for reducing childhood mortality, however in India, studies
reveal that a meagre 15% women breastfeed within a day
of birth and 37% breastfeed at one month of birth and only
55% infants under 4 months are exclusively breastfed.
• Integration of Nutrition and Health Education in the
school curriculum
Advocacy
• Advocate at all levels to build political commitment for
effective implementation of health and development
programmes.
To reiterate the importance of appropriate infant feeding
practices, each year Global Breastfeeding Week is
observed all over the world, during the first week of August.
This year the theme was “Exclusive Breastfeeding for the
first six months: Achieving the Gold Standard - Safe,
Sound, Sustainable''. In a national partners meet organised
by the Ministry of Health and Family Welfare (MoHFW) on
August 7,2004, about 150 representatives from the GO/
Research
• Initiate research into various aspects of nutrition to
enable selection of new varieties of food with high
nutrition values.
5
NGO, professional bodies and funding agencies
participated. The objectives were to launch a national
partnership for catalysing countrywide promotion of
breastfeeding and mobilize convergent support and actions
for improved infant feeding practices ensuring young child's
survival, growth and overall development.
Ms.Panabaka Lakshmi, Hon’ble Minister of State in her
keynote address reiterated the national commitment of
promoting exclusive breastfeeding for the first six months
of life. The discussions focused on efforts by GO/NGO,
promote BF in Reproductive and Child Health programmes
and areas for convergence and commitment of stakeholders.
Role of Traditional Birth Attendants (Dai) was highlighted in
supporting women in initiating breast-feeding within first hour
of life. Participants expressed a need to enhance coordination
among ICDS and Health Department at all level.
On behalf of NGO community, CHETNA committed to
promote the BF practices and recommend for women and
child friendly polices and programmes.
Strengthening Integrated Child
Development Services (ICDS)
In response to the need for enhancing community
participation and strengthening the existing efforts of
Government through ICDS for improving the health and
nutritional status of women (pregnant and breastfeeding)
and infants, as a recsource, CHETNA built capacities of
ICDS functionaries and adolescents, through training,
teleconferencing and widespread dissemination of
education material in Rajasthan, Gujarat and Madhya
Pradesh States of India.
“Early Childhood Stimulation programme”
- Community’s challenge to malnutrition
Child In Need Institute's (CINI) life cycle approach, which
targets the critical periods of life stages (pregnancy, 0-2
years & adolescence), currently has 0-2 years as one of its
main focus areas. Beyond 2 years, CINI works closely with
the system and the children become part of few
government programs like Health, Integrated Child
Development Services scheme (ICDS) and Education,
which would ensure healthy childhood, proper development
and education. However, due to several constraints these
programmes do not always reach out to the household
level and cover all.
Since parental, family & community involvement is pivotal
for effective early childhood care & stimulation, CINI's “
Early Childhood Stimulation programme", aims to provide
the children a better start in their life by focusing on early
childhood development and ensuring education for 2-6 year
olds through a community-based programme involving
adolescents.
Adolescents are involved to create awareness on
malnourishment amongst the mothers in the community
and in the health service centres learn about effective
indigenous methods to deal with it. Mothers are also
sensitized on proper nutrition during pregnancy to prevent
low birth weight, exclusive breast feeding and early
childhood care along with the need for complete and timely
immunization. Adolescents who are prospective parents
also get empowered with their knowledge about growth,
development and nutritional care of the children.
Village Health and Education Committee (VHEC)
comprising of members from the stakeholders and the
community, play a pivotal role in identifying the
adolescents and monitoring the process of developments.
They also support the activities of the ICDS.
The programme has been initiated in both rural and the
urban belts of West Bengal. In case of CINI ASHA- the
urban unit, the last one and a half years’ experience has
been very encouraging. To ensure sustainability the
concept of foster care for children of working mothers in
the community is also being considered. It is realized that
the concept is possible to translate into action only if all
the mothers in the community are properly sensitized on
early childhood care and nutrition. When well nurtured and
cared for in their earliest years, children are more likely to
survive, to grow in a healthy way, to have less disease and
fewer illnesses and to fully develop thinking, language,
emotional and social skills.
Nutrition-Road to better life
CINI's experiences
I am a mother of a 10-year-old child, Purba. Both my
husband and myself are HIV positive. My husband died of
HIV/AIDS. Purba is a severely malnourished child. We
were referred to the Bandhan HIV/AIDS Unit of CINI by the
local self government of our area. Looking at Purba’s
condition, she was asked to undergo HIV test and
unfortunately she was declared HIV positive.
I am very concerned about Purba who had been sick for a
couple of years. While initiating the treatment, Purba's
weight was measured to be only 16 kg. She was
immediately admitted to CINI Nutrition Rehabilitation
Centre (NRC), as an urgent need of proper nutritional
treatment was also felt along with prompt medical attention.
In NRC, Purba was provided with the right amount and type of
food required by her. Being an HIV positive peron, I was made
aware of the nutritional aspects and received training on
nutritional aspects and the effect of malnourishment to enable
me to follow the practices at home. Easy to follow methods to
prepare simple and low cost foods at home which has high
nutritive value was demonstrated. I also participated in a
training programme organized by CINI for the caregivers of
people living with HIV/AIDS. We were taught about
maintaining proper hygiene along with good nutrition.
Network News
Gradually Purba's health improved at NRC as her weight
increased to 19 kg within a span of just two weeks. She
was discharged from CINI and sent home. But soon she
fell seriously ill. At that time she was referred to Medical
College and Hospital for further treatment and she got
admitted there.
The CHIN partners presented their efforts in a
meeting at Child in Need Institute, Kolkatta during
July 26-27, which clearly evidenced a breadth of
activities on rights, advocacy, resource development,
research and communication work in the area of
women’s health from conception to old age.
As a child, my Purba lost her childhood. At an age, when
she is expected to play around, she has been made to
face a hard reality of life. This made her extremely
withdrawn. Realising this she was constantly counselled to
help her overcome her depression. CINI Team explained
me to take proper care of my child as well as manage the
acute stress I was facing everyday. While I was fighting
not only for the barest sustenance, but on the other hand I
was making efforts to survive and make my child survive!
Followed by this, the partners participated in a
workshop on "Communicating for Advocacy-A
rights based approach” during July 28-30 at Kolkatta,
organized jointly by Association for Women with
Disabilities, West Bengal, Healthlink Worldwide,
United Kingdom and Social Assistance &
Rehabilitation for the Physically Vulnerable,
Bangladesh.
A session on “Cross learning” between
Communicating for Advocacy (CFA) partners and
CHIN was organized on July 31,2004. The
objective was to provide a forum for exchange
between the networks wherein the lead partners
contributed in the discussions. CHIN envisages
contributing to CFA in building capacities on
different health issues, IEC material development,
website development, resource exchange and
networking.
However continuous counseling and nutrition support led to
the improvement in our health. Purba has joined her school
and is very sincere in attending it regularly. It is difficult for
Purba to understand the adversity of the disease, but she
sustains the pain with the dreams in her eyes, which she
aims to fulfill.
Communicating Health through Radio
Programmes
CHETNA collaborated with All India Radio (AIR) to
broadcast a series of 13 episodes entitled “Parivar nu
Sukh” (Family’s Happiness) during April to June 2004 and
provided technical input and facilitated the process.
Resources & Publications on Health and
Nutrition
The objectives were to harness the power of radio to air
health programmes and to provide a platform to people of
all age groups particularly the adolescents to share their
experiences and to create awareness about various health
issues affecting them. A total of 13 episodes on different
issues of adolescent health and development were
broadcast.
I.
Available at CHETNA
•
Early Childhood Development- CHETNA's perspective
paper
•
Breastfeeding-Nature's way
The experience has been documented and the recorded
programme is available at CHETNA in Gujarati language.
•
•
Reports on Celebration of Nutrition Week
RUHSA’s Contribution Towards Achievement of
Millennium
•
Health and Nutrition Exhibition
•
Anaemia kit
•
Manual on Complimentary food
•
Camp as an Approach for Parent's Education
Balmela (Children's fair) and Gram Yatra (Village Rally)
These publications are available for sale.
As a part of its poverty alleviation activities, for the first
time, RUHSA studied a sample of 180 individuals. Nearly
75% of the indicators used for measuring the MDGs were
met by RUHSA. Download the document
from:www.uisanet.unisa.edu.au/aart/Frank/
RUHSA%20student1 reports.htm
Contact: Ms.Vibhuti Vaidya, chetna@icenet.net
7
2.
Papers on Nutrition (year 2000 onwards)
•
White paper on National strategy to prevent
micronutrient malnutrition in women and children
through ICDS, 2000
•
Women and nutrition: Victims or decision makers, 2000
•
Enabling community participation in nutrition initiatives
for better health, 2000
•
•
Gender issues in nutrition, 2000
•
• Report of a seminar on HIV/AIDS advocacy,
Website: www.hindu.com/2004/07/24/stories/
2004072406500300.htm
Forgotten wealth, women’s health! - empowering
women to meet health and nutritional needs, 2001
Ensuring health through gender equality, 2001
• Health dialogue (newsletter)
• Issues: 1. Palliative care 2. Domestic Violence
• Health Development CD ROM issue 6, TALC, UK includes information about CHIN and CHIN News. The
CD is available free of charge. Email: info@talcuk.org
•
Food and Nutrition Security and Empowerment - a
concept of CHETNA, 2001
•
Building on people’s knowledge for better nutrition and
health, 2003
3.
Resources and Publications available on health and
nutrition with other organizations (only the recent
ones are listed)
Newsletters
• NGO Capacity Analysis - A toolkit for assessing and
building capacities for high quality responses to HIV/
AIDS, International HIV/AIDS Alliance, Email:
publications@aidsalliance.org
News you can use
Short course on "Evaluation of Behaviour Change
Programme in the context of emerging Reproductive and
Sexual Health Issues" during December 13-18,2004 at
Kolkata organised jointly by CINI and London School of
Hygiene and Tropical Medicine
• Breastfeeding and Food Security, BPNI, New Delhi,
Email: bpni@bpni.org
• RRC-VHAI Newsletter (Abhilasha) on Priorities in Child
Health and Nutrition, VHAI, New Delhi, Email:
vhainc@vhai-rrc.org
For details contact: crc@cinindia.org
• Nutrition News, National Institute of Nutrition, 2003
An appeal to readers
Reports
Would you like to be a Voice for the rights of the Vulnerable
Group, then read on...
• The State of the World’s Children 2004, UNICEF
Email: pubdoc@unicef.org
The CHIN partners have expertise and varied experience
and are willing to support you.
The Role and Rhyme of Public Distribution in India, Food
and Civil Supplies
Contact any of the partners for Capacity Building
workshops, Ordering and Developing IEC materials, as a
Resource or Consultant for any of your projects/
programmes/seminars or Conferences related to
development concerns.
Books
• Children in Globalising India - challenging our
conscience, HAQ: Centre for Child Rights, Email:
haqcrc@vsnl.net
• Flip book on guidelines for nutrition of children below six
years
Support us to support the vulnerable groups in India
For details contact:
CHETNA
chetna@icenet.net, info@chinindia.org
CINI
crc@cinindia.org
CMAI
varuldas@cmai.org, reena.luke@cmai.org
RUHSA
abel_rajaratnam@hotmail.com
Healthlink Worldwide
curtis.d@healthlink.org.uk
aljubeh.k@healthlink.org.uk
- Set of 5 books on Child Care and Health Education
Contact: UNICEF, ECD - Learning Resource Centre,
Department of HDFS, Faculty of Home Science,
M.S.University, Vadodara
Websites
Global nutrition data banks - to analyse global and regional
malnutrition trends and assess progress towards achieving
national and global goals. Website: www.who.org
Recent publications on other issues by CHIN partners
and other organisations
• Reports on State level Consultation on Young People:
Towards Healthy Future, CHETNA
• Booklet on Adolescent Sexuality in Tamil, RUHSA
8
Alok Mukhopadhyay
Member
Executive Committee, National Nutrition Mission
National Commission on Macroeconomics & Health
National Commission on Population
National AIDS Control Board
Empowered Action Group
Government of India________________
B-40, Qutub Institutional Area,
New Delhi-110016
Phone : 26518071-72, 51688152-53
Fax : 26853708 E-mail : vhai@vsnl.com
August 30, 2004
CE-3
Ms. Thelma Narayan
Coordinator
Community Health Cell
367, Srinivasa Nilaya
Jakkasandra 1 Main, 1 Block
Koramangala
BANGALORE - 560 034
Dear Thelma,
National Nutrition Mission
I thank you for your important response to my letter regarding the National
Commission on Macroeconomics & Health. We will be using your feedback
substantially while preparing the report of the Commission.
Keeping in view the concern of the present Government on the issue of Food
Security and Nutrition, a National Nutrition Mission has been set up under the
Prime Minister with following Terms of Reference:
1.
2.
3.
4.
5.
6.
7.
To review and revise the goals set out in the National Nutrition Policy
1993 and the National Plan of Action on Nutrition 1995, keeping in view
the present nutrition profile of the country;
To review the existing strategies adopted by the various Ministries
concerned with nutrition and revise them for achieving the goals set out
by the Mission;
To put in place effective mechanism for coordinating the efforts of
different Ministries concerned with implementation of nutrition
programmes to subserve the nutrition goals;
To review the systems of data collection and monitoring of the nutrition
status across different regions, groups and particularly the vulnerable
population of the country;
To review research & development and dissemination in the field of
nutrition, specially regarding low-cost balanced diet, safe drinking water
& sanitation, women & child development and health & family welfare;
To address special problems of nutrition during natural calamities; and
Any other nutrition related issues arising from time to time.
The Mission includes 8 Chief Ministers of States, which have serious Food
Security and Nutrition related problems and the Chief Ministers of Tamil Nadu,
Punjab and Kerala, who have done reasonably well. The Mission also includes
Deputy Chairman (Planning Commission) as well 8 Cabinet Ministers of related
Ministries. To ensure that the Mission’s work is speeded-up, focused and
accomplished in an energetic manner, an Executive Committee of the National
Nutrition Mission has also been set up with the following Terms of Reference:
1.
2.
3.
4.
5.
To identify nutritionally backward regions and groups in the country
requiring special focus on implementation of nutrition programmes;
Close monitoring of implementation of the nutrition programmes with
particular attention to resource constraints, institutional bottlenecks or
any other matter affecting service delivery;
Evolve mechanisms for coordination of all the nutrition related
programmes both at the policy and implementation levels;
Conduct of evaluation and impact studies of the programmes and
identify mid-course corrections in strategies and implementation issues;
and
Any other function vested on it by the Mission.
As a Member of the Executive Committee of the National Nutrition Mission and
keeping in view your concern on the issue covered by the Mission, I am requesting
you to send me your feedback, experiences and recommendations. If you also
have any relevant publication, literature or documents, the Mission will greatly
benefit from them. At this stage, you can also suggest any other issue that you
might find important for the Mission to consider.
With best wishes,
Sincerely yours,
Alok Mukhoapdhyay
Member
Executive Committee, National Nutrition Mission
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Sources:-
Natural foods are poor sources of vitamin D.
Small amount is present in
egg yolk, liver, and fish egherring, sardine, tuna and salmon fish liver oils,
cold liver and halibut oil also contain vitamin D.
Sunlight cannot always be
depended upon to supply the body with adequate U.V.R. for synthesis of vitamin D.
Because*, these rays are easily strained out by dust, fog, smoke, clothing and ordin
Fortification of milk i.e. 400 I.U./quart of milk could be an
ary window glass.
ideal solution because milk is consumed by growing Children and becauseit contains
calcium and phosphorous whose utilization it favours.
Deficiency;- Occurs whenthore is prolonged, insufficient intake of vitamin D or in
dark, overcrowded section of cities where sunshine cannot penetrate through fog,
Dark skinned individuals are more susceptiblies than those with
smoke, and soot,
shite skin.
Rickets:-
from the intestine.
results.
1. Rickets,
2. Tetany, 3. Dental caries, 4. Osteom
alacia.
ctux
and
Deficiency of vitamin Dxtc inadequate absorption of ealeixim/phosphorous
Manifestations are:-
Thereby faulty aineralization of bone and tooth structures
Thus., the inability of soft bonesto withstand stress of weight leads to
skeletal malformation.
Afully developed ca/s* of ricket shows:1. Delayed closure of fontanelles softening of skull, i.e., cranobabes bossing
of the forehead hotcross bun.
2. Soft fragile bones which are widened at ends of long bones.
Bowing of legs
and enlargement of costochondral junction results in rows of knobs resembling
beads:- called Rectifies rosary.
Projection of the sternum produces pigeon breast.
There is also depression of ribs and narrowing of pelvis apart from kyphosis.
3.
Enlargement at wrists, ankles and knees may be manifested as knock knees.
4.
POORLY developed muscles and lack of muscle tone produces, (pot belly formation),
There is also delayed walking.
5.
Restlessness and nervous irritability.
6.
Low xgK0r®siE
II
Tetany:1.
inorganic blood phosphoruns with high secum phosphatase.
Resilts from abnormal calcium $nd puBcmofous metabolism due to
failure of absorption of calcium or vitamin D.
ii.
insufficient dietary calcium and vitamin D.
iii.
from disturbance of parathyroids.
...3
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Symptoms:- Shart flexion of wrists and ankle joints, muscle twitching, cramps and
eGsir&tstoss,
Treatment:- Calcium for acute spasons liberal diet/ in calcium and vitamin D.
concentrate.
III
<AxA<tUlen-x
Dental carries;- Delayed dewtiwn, malformation of teeth and predisposition of
dental carries.
Osteomalacia;-
IV
Is adult rickets which results from failure of calcification in
respect of other metabolic processes.
Caused by lack of vitamin D and clacium.
Also, possible when there is interference with fat absorption.
One third of cases
may be due to inherent resistance to vitamin D.
This is specially common in our women who are pregnant or lactating and who are
indoor most of the time, also among Muslim woman who observed ’purdha’.
Symptoms:i) softening of bones - so severe as to produce deformities specially in bones of
legs, spine, thorax and pelvis.
ii)
iii)
pain of rheumatic type in bones of legs and lower part of back.
general weakness specially difficulty in climbing xittrs
stairs, patiente
haswaddling gait.
iv)
spontaneous multiple fractures.
Treatment:- High protoin and high caloric diet. Therapeutic doses of vitamin D.
HvnervitaminQsj.s:-
Nau.sea diarrhoea weightless, pelyruis nocturia, fatigue, ronal
damage, calcification of eoft tissues, eg., heart, blood vessels, bronchi, and
tubules of kidneys.
*■»*»«-***•«■**<*■
Position: 1798 (2 views)