Role of Nutritionists in Strengthening the Nutritional Scenario @ Base of Pyramid

Rekha Sharma R.D.President Indian Dietetic Association,Director, Nutrition and Dietetics, Diabetes Foundation (INDIA)Former Chief Dietician, All India Institute of Medical Sciences, New Delhi.

Nutritional Challenges at BOP

Increased birth rate Less of education Increased death rate - Increased IMR Less medical care Less finances Less nutritious foods Nutritional Deficiencies Infectious diseases Chronic diseases Poor maternal and child health

Nutritional challenges

India faces a double burden

Under nutrition and poor maternal health Increase in over weight and obesity

(Under privileged migrant population

from rural areas to urban slums)

Nutritionists role is mandatory in both

Nutritional challenges on Migration to cities(urban slums)

loss of traditional diet, Irregular ,faulty eating High stress –work Family deprivation Lack of physical activity Smoking , tobacco

chewing, alcohol

Over weight and obesity

Coronary Heart disease Diabetes Hypertension Metabolic syndrome Stroke Hypercholesterolemia Hypertriglyceridemia

Incidence of obesity& related disorders – Migrant population Young Women (18 – 25 years) = 13.2% Delhi, DST Trial (2000)

Urban slum ( 35 years) = 40.2% European Journal of Clinical Nutrition (2001)

Urban Slum (30-60 years) = 28.2% Delhi, (2002) DST Trial Women migrant study 4,621( >35 years) overweight urban areas = 64 % rural areas = 36 % Hypertension >140/90 mm Hg = 50% Hyperlipidaemia Cholesterol > 200 mg = 25% Diabetes Blood sugar >126 mg% = 3 - 14 %

DST trial (2009)

Coronary Risk Factors in Urban Underprivileged New Delhi, India

Misra et al., Eur J Clin Nutr, 2001 Misra et al., Int J Obesity, 2001 Misra et al., Diab Res Clin Pract, 2002

0

15

30

45

60

Percentage

High W-HR

High BMI

High body fat

Hypertension

Diabetes

Transition in Dietary Habits

Carbohydrates from whole grains were being replaced by refined products

Carbohydrates were also being replaced by unhealthy fats specially by SFA and TFA

Fibre content of diets reduced Traditional foods replaced by modern refined

foods Diet :Low in MUFA ,n3 ,fiber, high in refined

Carbohydrates ,SFA,TFA ,n6

Other side

Other side :Macro and Micronutrient deficiency

Deficiency of vitamin minerals often occurs in conjunction with PEM

One third of the World’s people do not fulfill their physical and intellectual potential because of unrecognized deficiencies of vitamins and minerals- Vitamin A, Iron ,Iodine, folate etc.

• Survival

• Development

• Growth

• Health

• Productivity

• Economic Growth

Malnutrition affectsMalnutrition affects::

Most Vulnerable Groups are . . .

• 0-6 year children

• Pregnant Women

• Lactating Mothers

• Adolescent Girls

• Aged

45.9% Underweight Children (Under 3 years)

22.0% Low Birth Weight Babies ( for whom birth weight reported)

33.0% Women with Chronic Energy Deficiencies (30% in Men)

70.0% Children (6-59 months) with anaemia

55.0% , 24.0% Women and Men respectively were

anaemicVitamin A deficiency & Iodine Deficiency Disorders continue to be public health

problems

India has unacceptably high level of India has unacceptably high level of malnutrition malnutrition (NFHS-III)

The picture (as per UNICEF and MI VM global progress report)

Iodine deficiency

Estimated to have lowered the Intellectual capacity by 10-15 percentage points

Iron deficiency in 6-24 m olds

Mental development impaired by 40-60%

Vitamin A deficiency

Impaired the immune system leading to an estimated one million children not reaching their 5th birthday

Iodine deficiency in mothers

18 million babies being born mentally impaired

The picture [as per UNICEF and MI VM global progress report

Folate deficiency

Approximately 200,000 babies with severe birth defects and 1in 10 deaths from heart disease in adults

Severe Iron deficiency

Causes loss of life more than 60,000 young women in pregnancy and child birth and loss of 2% GDP.

This is high economic cost on virtually every developing nation---world bank

Nutritional Challenges

UNICEF (2009) data shows infant mortality to be declining steadily, but is still 1726 thousand deaths for children below the age of 5 against 26787 thousand births .

40% of children below the age of 5 are under weight.

Despite the country's growing economy and an ambitious rural health initiative Over 100,000 women die from pregnancy-

related causes each year – highest in the world

Nutritional Challenges

While breastfeeding is nearly universal in India, less than half of children (46%) are fed only breast milk for the first 6 months, as recommended

Only 23.4% of children are breastfed within one hour of birth and the prevalence is significantly lower among the non-educated mothers and in rural areas.

Only 55.8% of children aged 6-9 months receive solid or semisolid food and breast milk ,making complementary feeding a high-priority to be addressed

The higher the education of the mother, the better the nutrition status of themselves and their child.

National Family Health Survey (NFHS-3)

Way Forward

Prevention and cure for Anemia:

Increasing the iron content of food through dietary intake Increasing the iron content of food through fortification Increasing iron intake through supplementation Reducing blood loss by treating for parasites Reducing blood loss from hemorrhage by improving birthing or

abortion practices and post-abortion care

PM's National Council on India’s Nutrition Challenges - Iron fortified Iodized Salt to be promoted to battle malnutrition for prevention and cure of Anemia

One cost effective way of increasing the intake of iron, is fortification of salt with iron in addition to iodine

Nutrition Programmes Improving mothers' feeding and caring behaviour

with emphasis on infant and young child feeding and maternal nutrition , during pregnancy and lactation. 

Improving household water and sanitation. 

Strengthening the referral to the health system, with emphasis on prevention and control of common child diseases including acute malnutrition. 

Providing micronutrients. Actual implementation follow ups.

Programme recommendations:

Supplementary feeding activities need to be better targeted towards those who need it most ,with clear criteria set for quality assurance and accountability. 

Growth-monitoring activities need to be performed with greater regularity, with an emphasis on using this process to help parents understand how to improve their children's health and nutrition. 

Involving communities in the implementation and monitoring of programmes and anganwadi centers ,to improve the quality of service delivery and increase accountability in the system.

0-6 months is critical, 6-12 is next We allow child under nutrition to set in - with

poor feeding ( Breast feeding and complementary feeding)

Neonatal infections, Diarrhea and pneumonia give 2/3rd mortality in 1st year

According to WHO, other 2/3rd mortality is related to poor feeding practices

Exclusive breastfeeding prevents Exclusive breastfeeding prevents child malnutritionchild malnutrition

Way Forward

Prevention and cure for under nutrition in children

There are ten proven, high-impact interventions ,that can help in bringing, child under nutrition , figures down:

1. Timely initiation of breastfeeding within one hour of birth.

2.  Exclusive breastfeeding in the first six months of life3.  Timely introduction of complementary foods at six

months4. Age-appropriate foods for children six months to two

years5.  Safe and hygienic complementary feeding practices

Way Forward

6. Full immunization and bi-annual vitamin A supplementation with deworming

7. Appropriate feeding for children during and after illness

8.  Therapeutic feeding for children with severe acute malnutrition

9.  Adequate nutrition and anemia control for adolescent girls

10. Adequate nutrition and anemia control for pregnant and breastfeeding mothers

UNICEF

• Fortification

• Supplementation

• Dietary diversification

• Nutrition and health Education

Nutrition Interventions to combat Nutrition Interventions to combat Micronutrient MalnutrtitionMicronutrient Malnutrtition

• Horticulture interventions: Promote the Nutritious crops by providing incentive to the farmers

• Nutrition and Health Education to promote healthy eating patterns – LONG TERM SUSTAINABLE intervention – BEHAVIOUR CHANGE

• Promotion of correct Infant and Young child Feeding Norms

• Promotion of low cost locally available nutritious food – by providing them recipes/ or demonstration of the recipes

• Promotion of seasonal fruits and vegetables

• Use of Hygiene and sanitary practices

• Use of Safe Drinking water

• Use of Mass media to promote healthy Food ,Safe , Sanitary and hygiene Practices

DIETARY DIVERSIFICATION to combat DIETARY DIVERSIFICATION to combat Micronutrient MalnutritionMicronutrient Malnutrition

Fortification and supplementation

Recipes suitable for infants and children Recipes which can be prepared daily specifically for

the infant Adult food modified to suit children’s needs Protein-rich supplements that may be added to the

family diets Ready-to-use infant weaning foods can be prepared Recipes suitable for preschool children Nutritious snacks for infants and preschool children

Nutrition Education

Breast feeding practices Weaning foods at proper age Easy recipes with supplementation

Cereal + Pulse mixes Use of kitchen garden fresh foods and leafy

vegetables Use of millets , whole grains vs refined

foods Hygiene and clean water

Conclusion

Nutrition Education to mothers Breast feeding practices Weaning food practices Recipes – easy to prepare and economical Modification of family meal Supplementation of foods Migrant population - on food selection

guidance –use whole grains and good quality fats.

Thank you