M.Sc. in Food and Nutrition Sciences: Karnataka State Open University

KARNATAKA STATE OPEN UNIVERSITY
Mukthagangothri, Mysuru – 570 006
M.Sc. in Food and Nutrition Sciences

CBCS Scheme
II Semester
MFNSDSC-2.2: Community Nutrition

M. Sc.
FOOD AND NUTRITION SCIENCE
CBCS Mode
SECOND SEMESTER
MFNS DSC 2.2: COMMUNITY NUTRITION
(Blocks -I, II, III and IV)

MFNSDSC 2.2: COMMUNITY NUTRITION
COURSE DESIGN
Prof. Sharanappa V. Halse Prof. Ashok Kamble
Vice Chancellor Dean (Academic)
Karnataka State Open University Karnataka State Open University
Mukthagangotri, Mysuru-570006 Mukthagangotri, Mysore-570006
COURSE CO-ORDINATOR
Dr. Hemalatha M.S.
Chairperson, Department of Food Science and Nutrition
Karnataka State Open University, Mukthagangothri, Mysore-
570006
COURSE WRITERS
NAME COURSE BLOCKS UNITS
Dr. Krishnaraj V. MFNSDSC 2.2 Block I 1, 2, 3, 4, 13, 14, 15 &
Assistant Professor Block IV 16
Department of Food Science
and Nutrition Department,
KSOU, Mysuru
Prof. Neena Joshi MFNSDSC 2.2 Block II 5, 6,7, 8, 9, 10,11, 12

Retired Professor Block III & 13
Department of Food Science
and Nutrition, GKVK,
Bengaluru
COURSE EDITORS
Prof. Jamuna Prakash MFNSDSC 2.2 Block I 1, 2, 3, 4, 5, 6,7, 8, 9,
Retired Professor, Block II 10,11, 12, 13, 14, 15 &
Department of Food Science Block III 16
and Nutrition, University of Block IV
Mysore, Mysuru
PROOF READING AND EDITORIAL

Dr. Hemalatha M.S. MFNSDSC 2.1 Block I 1, 2, 3, 4, 5, 6,7, 8, 9,
Assistant Professor Block II 10,11, 12, 13, 14, 15 &
Department of Food Science Block III 16
and Nutrition Department, Block IV
KSOU, Mysuru
SLM Editorial Committee
Dr. Hemalatha M.S. Chairman & Convener
Chairperson, Department of Food Science and Nutrition,
KSOU, Mysore
Dr. Anitha C. Member

Assistant Professor, Department of Food Science and Nutrition
KSOU, Mysore
Dr. Vanitha Reddy Member

Assistant Professor, Department of Clinical Nutrition and Dietetics
JSSAHER, Mysore
PUBLISHER
The Registrar
Karnataka State Open University,
Mukthagangotri, Mysore-570006
Developed by Academic Section, KSOU, Mysore.
Karnataka State Open University (KSOU), 2022
All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any
other means, without permission in writing from Karnataka State Open University.
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TABLE OF CONTENTS
Page No
Block I - CONCEPT AND SCOPE OF COMMUNITY NUTRITION ASSESSMENT
Unit-1 Concept of Community 03

Unit-2 Assessment of Nutritional Status in community- anthropometry assessment 27
Unit-3 Clinical Assessment of Nutritional Status and Biochemical Assessment. 48
Unit-4 Dietary Assessment – advantages and disadvantages. 76
Block II - NUTRITIONAL PROBLEMS
Unit-5 Macro nutrient deficiency and excess 89

Unit-6 Vitamins deficiency and toxicity 115
Unit-7 Mineral deficiency and toxicity 141
Unit-8 Major Nutritional Problems Prevalent in India and programmes to combat 166
them.
Block III - NATIONAL AND GLOBAL AGENCIES AND POLICIES FOR HEALTH AND
DISEASE
Unit-9 National and Global Nutrition Policy 197
Unit-10 National and Global Nutrition Programs 225
Unit-11 National Nutrition Surveillance System 249
Unit-12 Concept and Meaning of Food Quality and Food Safety 267
Block VI - COMMUNITY BASED HEALTH AND NUTRTION APPROACHES/
STRATEGIES
Unit-13 Health Based Interventions 300
Unit-14 Food Based Interventions 322
Unit-15 Nutrition Education Interventions 344
Unit-16 Nutrition Education – nutrition education and counseling 368
M. Sc. Food and Nutrition Science II Semester Community Nutrition
COURSE INTRODUCTION
Community nutrition deals with a variety of food and nutrition issues related to
individuals, families, and special groups that have a common link in terms of a particular
region, language, culture, or health-related issues. This segment covers public health nutrition
and nutrition education. Community nutrition is gaining importance in health promotion and
disease prevention since an individual's behavior is influenced by the living environment,
local norms, and beliefs. Nutritional assessment is the interpretation of anthropometric,
biochemical (laboratory), clinical and dietary data to determine whether a person or groups of
people are well nourished or malnourished (over-nourished or under-nourished). Biochemical
assessment is an essential component of nutrition assessment, the first step in implementing
the Nutrition Care Process (NCP) in clinical practice. Laboratory tests of patients’ blood,
urine, feces, and tissue samples are important indicators of nutritional status and organ
function. Almost no country in the world is exempt from some form of malnutrition, and diet-
related health conditions are still dominating the rank of the global health risk.
The body needs a variety of nutrients to stay healthy which is obtained from a
balanced diet. Minerals are needed in balanced proportions. Minerals interactions in foods,
digestive tract and within the body play a significant role in the way they are absorbed and
function in the body. The global burden of malnutrition is unacceptably high, with nearly half
of all deaths in children less than five years linked to poor nutrition. Stunting in early life can
have long-term effects on health, physical and cognitive development, learning and earning
potential, thereby placing an immense human and economic toll at the individual, household,
community and national level. Nutrition programmes are key turning points in
implementation strategies leading to food and nutrition improvement as a sound basis for
socio-economic development. Importance of food safety has gained more importance in
modern society due to expansion of trade networks when food began to be shipped long
distances. Health-based intervention is an organized effort to promote those specific
behaviors and habits that can improve physical, mental, and emotional health. Food-based
nutrition interventions have the purpose of improving food production and availability,
processing and conservation, supply and commercialization, as well as access and food
consumption. Nutrition education intervention should include information on physical
activity in addition to nutrition. Nutrition education presents general information related to
health and nutrition, often to groups in clinic waiting rooms or community settings.
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BLOCK-I: CONCEPT AND SCOPE OF COMMUNITY NUTRITION

ASSESSMENT
Community nutrition is the science related to the practical application of
nutritional knowledge in the field to identify and solve nutritional problems of population
groups in the community. Before we go into the details of the identification of the specific
nutritional problems, there is a need to learn about the concepts of community nutrition and
definitions of some terminologies. Further, it is also essential to know the basis for
identifying the nutritional and health problems and the basis for classification of nutritional
problems. A nutrition assessment includes computerized food intake analysis, clinical
nutrition body composition assessment (bioelectrical impedance), laboratory blood test if
applicable anthropometrics, and review of medications, lifestyle, and fitness indicators. It
aims at discovering facts and guiding action intended to improve nutrition and health.
Nutritional assessment can be categorized as direct assessment and indirect assessment.
The Biochemical assessment is an important component of the nutrition care process,
which must be interpreted with other methods (i.e., physical findings, patient history, and
anthropometrics) for accuracy. Nutrient concentrations in plasma do not reflect the amount
of the substance stored in body pools and may be influenced by disease, inflammation, and
recent dietary intake. The measurement of dietary intake is complex and presents
significant challenges, particularly at a group and population level. The appropriate
method of measurement will depend on the objectives of the surveillance and the types of
information required. For example, a policymaker may be interested in dietary intake data to
measure the behavioral response to a campaign to encourage healthy eating or to estimate
the differences between the nutrient intakes of a particular population subgroup. In this
block, the learner will know about these aspects.
LEARNING OUTCOME
After studying the Block on you will be able to;

 Explain the conceptualization of community,
 Understand the demography, health statistics, mortality rate, morbidity rate,
 Know the role of anthropometric measurement in assessing the nutritional status
of the individual.
 Discuss the different types of biochemical assessments.
 Study the importance of diet surveys in assessing the nutritional status.
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UNIT –I: CONCEPT OF COMMUNITY
STRUCTURE OF THE UNIT:
1.0: OBJECTIVES
1.1: INTRODUCTION
1.2: CONCEPT OF COMMUNITY
1.3: DEMOGRAPHY
1.4: HEALTH STATISTICS
1.5: MORTALITY RATE
1.6: MORBIDITY RATE
1.7: NUTRITIONAL ASSESSMENTS
1.8: NUTRITION SCREENING
1.9: NUTRITION MONITOR
1.10: MALNUTRITION
1.11: UNDERNUTRITION
1.12: OVERNUTRITION
1.13: SUMMARY
1.14: CHECK YOUR PROGRESS-1
1.15: 14 CHECK YOUR PROGRESS-2
1.16: GLOSSARY
1.17: REFERENCES
1.18: REFERENCES FOR FURTHER READING
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1.0: OBJECTIVES:
After studying this unit, you will be able to;
 Explain the conceptualization of community,
 Understand the demography, health statistics, mortality rate, morbidity rate,
 Know the difference between nutrition screening and nutrition assessment
 Describe the purpose of nutrition assessment in the community.
 Define nutrition monitor, malnutrition.
 Learn how to solve the nutritional problems in the community.
1.1: INTRODUCTION:
A community is a specific group of people who share common characteristics, e.g. a

common language, exposure to similar conditions, common lifestyle, or the same health
problem.
Nutrition is defined as a science concerned with the role of food and nutrients in the
maintenance of health. Nutrition as defined by Robinson (1982) is " the science of foods and
nutrients, their action, interaction and balance concerning health and disease, the processes by
which the organism ingests, digests, absorbs, transports and utilizes nutrients and disposes of
their end product".
Community nutrition deals with a variety of food and nutrition issues related to
individuals, families, and special groups that have a common link in terms of a particular
region, language, culture, or health-related issues. This segment covers public health nutrition
and nutrition education. Community nutrition is gaining importance in health promotion and
disease prevention since an individual's behavior is influenced by the living environment,
local norms, and beliefs.
Community nutrition is the science related to the practical application of nutritional

knowledge in the field to identify and solve nutritional problems of population groups in the
community. Before we go into the details of the identification of the specific nutritional
problems, there is a need to learn about the concepts of community nutrition and definitions
of some terminologies. Further, it is also essential to know the basis for identifying the
nutritional and health problems and the basis for classification of nutritional problems. In this
unit, we will learn about these aspects.
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Community nutrition is the study of assessing food and nutrition situations in

terms of identification of food and nutrition problems, causative factors, and possible
solutions both for prevention and cure of the problems.
Now you must have realized why community nutrition and health cannot be looked at
separately and how they are interlinked with one another. The nutritional problems of a
community are indicated by the nutritional status of the different groups of people in the
community. The nutritional status of population groups in a particular community is
influenced by a variety of factors. The manifestations of undernutrition and malnutrition vary
in type and degree from community to community through differences in food availability
and consumption patterns. A population group may survive for some time on a marginally
inadequate diet but may be more prone to disease and less efficient both physically and
mentally.
1.2: CONCEPT OF COMMUNITY NUTRITION:
The World Health Organization (WHO) defines a community as a social group

determined by geographic boundaries and/or common values or interests. A community can
also be defined based on a common interest or goal. Much successful health awareness and
disease prevention efforts such as improved services and awareness of certain community-
specific problems have been possible in common-interest communities. Community nutrition
initiatives aim at involving community nutrition and dietetics professionals to provide
nutrition services according to the needs of the individuals through primary, secondary, and
tertiary prevention.
 Primary prevention involves designing activities to prevent a disease or condition

before it occurs. Public health nutrition also focuses on the promotion of good health
through nutrition, primary prevention of nutrition-related illness, and maintaining the
nutritional health of populations.
 Secondary prevention involves planning activities related to early diagnosis and
treatment including screening for diseases.
 Tertiary prevention consists of designing activities to treat a disease state or condition
such as malnutrition or injury to prevent it from progressing further.
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These professionals intercommunicate with other professionals for a wide range of

education and human services such as child care agencies, social work agencies, services for
older individuals, and community-based epidemiological research.
Another branch, public health, and nutrition are viewed as the scientific diagnosis and
treatment of the community as a whole. Public health is defined as the science and art of
preventing disease, prolonging life, and promoting health and efficiency through organized
community efforts. Thus, community nutritionists and health workers can focus on the
community strengths, which could be education, support systems, and spirituality among
others, and provide nutrition knowledge to reduce healthcare costs.
1.3: DEMOGRAPHY
The term demography is made up of two words: "Demos", which means "population",
and "-graphy", which means "describe." One can then say that demography is the science that
researches and describes a population. More concretely, demography researches the size,
composition, and (age) structure, as well as the geographic distribution of human populations.
In addition, demographers look at how a population develops, changes, and reproduces over a
certain period. Three fundamental aspects are observed: The birth rate (fertility), the death
rate (mortality), and emigration and immigration (migration).
Figure-1: Quantitative Study of Human Populations
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Demography does not only research the current population (for example, a group of
people in a football stadium or at a music concert), but it works more with the factors that can
influence population change. Demographers look at the individual life courses, which mean
the time between birth and death, and what happens within this time.
Births, deaths, and migration are the core aspects of demographic analyses. Age and
gender are important factors that determine these aspects. Examples of demography:
• Age of death: A death within the first years of life and death at the age of 93 have
very different consequences for the human population. Both influence, however, the
development of the overall life expectancy of a population and its age structure.
• Age of mother at first birth: It makes a big difference if a woman is a 22-year-old

or a 36-year-old when she has her first child. The chances that she will have more children in
the course of her life are much higher in the first case than in the second. In that respect,
populations, where the average age of mothers at first birth is low, tend to have higher rates
of fertility and larger family sizes.
• Gender distribution among newborns: When there are inequalities in the gender
distribution among newborns for one or more generations, meaning an identified difference
in the number of newborn boys and girls, then this will have an impact on their life courses
later on. For example, there are fewer partners available to start a family, which can then
impact the birth rate.
In addition to age and gender, other factors can interact with population development
over a certain period: The frequency of marriage and marital status, health status, level of
education, the type of household, employment level, education level of women, and so on.
For example, marital status in the reproductive phase of life, when men and women can
reproduce, can influence the birth rate, as can the level of education of women and their
opportunities in the labor market.
1.4: HEALTH STATISTICS
Health statistics are numbers that summarize information related to health.

Researchers and experts from government, private, and non-profit agencies and organizations
collect health statistics. They use the statistics to learn about public health and health care.
Some of the types of statistics include:
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 How many people in the country have a disease or how many people got the disease
within a certain period
 How many people of a certain group have a disease? The groups could be based on
location, race, ethnic group, sex, age, profession, income level, and level of education.
This can help identify health disparities.
 Whether a treatment is safe and effective
 How many people were born and died? These are known as vital statistics.
 How many people have access to and use health care
 The quality and efficiency of our health care system
 Health care costs, including how much the government, employers, and individuals
pay for health care. It could include how poor health can affect the country
economically
 The impact of government programs and policies on health
 Risk factors for different diseases. An example would be how air pollution can raise
your risk of lung diseases
 Ways to lower risk for diseases, such as exercise and weight loss to lower the risk of
getting type 2 diabetes
Health statistics are used to understand risk factors for communities, track and
monitor diseases, see the impact of policy changes, and assess the quality and safety of health
care.
Health statistics are a form of evidence or facts that can support a conclusion.
Evidence-informed policy-making, "an approach to policy decisions that are intended to
ensure that decision making is well-informed by the best available research evidence," and
evidence-based medicine (EBM), or "the conscientious, explicit, judicious and reasonable use
of modern, best evidence in making decisions about the care of individual patients" are
essential to informing how best to provide health care and promote population health.
Health statistics measure four types of information. The types are commonly referred
to as the four Cs: Correlates, Conditions, Care, and Costs. The first section of this course
examines each type of information.
About Health Statistics Modules:
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 Correlates: See how to measure the risk factors and protective factors that impact our
health.
 Conditions: Learn to assess how often and how badly diseases impact a community.
 Care: Dig into how health care is delivered to the communities that need it, to treat
disease and illness.
 Costs: Get more information on what health care costs, are and why.
1.5: MORTALITY RATE
Mortality is defined as the demographic event of death. Since death is a biological

phenomenon that occurs just once to each individual, the analysis is simpler than, say, the
study of fertility wherein the event of birth can occur with varying frequency among women.
Mortality analysis begins with good quality data on deaths and population. These data are
conventionally obtained from vital registration systems and population censuses respectively.
The crude death rate and the specific death rates (age, sex, age-sex, age-sex-cause of death
specific) are simple measures of mortality. The other measures are based on the life tables.
Mortality rate or death rate is a measure of the number of deaths (in general, or due to
a specific cause) in a particular population, scaled to the size of that population, per unit of
time. The mortality rate is typically expressed in units of deaths per 1,000 individuals per
year; thus, a mortality rate of 9.5 (out of 1,000) in a population of 1,000 would mean 9.5
deaths per year in that entire population or 0.95% out of the total. It is distinct from
"morbidity", which is either the prevalence or incidence of disease and also from the
incidence rate (the number of newly appearing cases of the disease per unit of time).
1.5.1: Measures of Mortality

Crude Death Rate:
The crude death rate is calculated by dividing the number of registered deaths in a
year by the mid-year population for the same year. The rate is expressed as per 1,000
populations.
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This rate has a simple interpretation, for it gives the number of deaths that occur, on
average, per 1,000 people in the community. Further, it is relatively easy to compute,
requiring only the total population size and the total number of deaths. Besides, it is a
probability rate in the true sense of the term. It represents an estimate of the chance of
dying for a person belonging to the given population, because the whole population may be
supposed to be exposed to the risk of dying of something or the other.
However, it has also some serious drawbacks. In using the CDR, we ignore the fact
that the chance of dying is not the same for the young and the old or for males and females,
and the fact that it may also vary concerning race, occupation, or locality of dwelling.
Specific Death Rate:
The crude death rates for specific causes of death are calculated similarly by
selecting deaths due to specific causes as the numerator and mid-year population as the
denominator. Thus,
The rates could be made specific to sex by selecting the numerator and the
denominator for each sex of the population.
Age Specific Death Rates (ASDR):
The age-specific death rates are calculated from deaths and populations both specific
to each age (or age group) of the population. Thus,
Where 'x' indicates the age and 'n' is the class interval of age.
The age-cause-specific death rates are obtained by selecting deaths of a specific age
and cause a group of the population as the numerator
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It should be noted that the sum of the cause-specific rates overall causes equals the
crude death rate. Similarly, the sum of the age-cause-specific death rates equals the age-
specific death rate at a given age.
Neo-natal Mortality:
The mortality of live-born before completing four weeks or 28 days of life is known
as neonatal mortality. The equation to calculate neonatal mortality is as follows:
Post-neo-natal Mortality rate:

The mortality of live-born after 28 days after birth, but before reaching the age of one
year is called post-neo-natal mortality.
The equation is as follows:
Perinatal Mortality rate:

“Deaths between the periods of seven months of gestation (stillbirth) to the first week
of life. The Perinatal mortality rate is defined as the number of deaths during the Perinatal
period (the sum of late fetal deaths and early neonatal deaths) occurring in a community
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during a specified year expressed as per 1000 of the sum of live births and stillbirths during
the same year.”
Perinatal mortality rate
Infant Mortality rate:

The mortality of life born under one year of age is known as infant mortality. Infant
Mortality Rate: (IMR) is defined as, "the number of infant deaths occurring in a community
within a specified calendar year per 1000 live births in the same community during the same
calendar year.”
It is a good indicator of the health status of a given area or population since it tends to reflect
the population's socio-economic condition and status of health services. It can be calculated
as follows:
Maternal Mortality rate:

Maternal death is defined as, “the death of a woman while pregnant or within 42 days
of termination of pregnancy irrespective of the duration and site of the pregnancy, from any
causes related to, or aggravated by the pregnancy or its management, but not from accidental
or incidental causes” (WHO 2018).
1.6: MORBIDITY RATE

Morbidity rate refers to the rate at which a disease or illness occurs in a population
and can be used to determine the health of a population and its healthcare needs. Illnesses can
range from acute to chronic, long-lasting conditions.
 A morbidity rate tracks how acute and chronic diseases infect a population.
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 Morbidity rates can be used to determine the overall health of a population.

 By using a morbidity rate, the health care needs of a population can be determined.
 These rates are also used in actuarial industries, such as insurance.
 Insurers use morbidity rates to develop policies for coverage, determine premiums,
and set aside benefits for insurance claims.
According to the Centers for Disease Control and Prevention, morbidity refers to "any
departure, subjective or objective, from a state of physiological or psychological well-being."
In simpler terms, morbidity is the word used to describe the instance of a disease or
illness, including acute and chronic conditions. An acute condition may be caused by a virus
and doesn't last very long, like a cold. Chronic conditions are more demanding on a
population as they tend to be long-lasting, cost more to treat, and may need multiple layers of
health or mental health care.
They include diseases such as:
 Diabetes
 Cancer
 Heart disease
 Obesity
 Mental health conditions
Because morbidity rates measure the frequency at which illness and disease occur in a
population, they are used in various ways in the public and private sectors. For instance,
governments may use morbidity rates and other health statistics to research health and health
care. This includes costs, the success and failures of government programs, and the quality of
health care systems.
Morbidity Rate vs. Mortality Rate:
People often confuse morbidity (rates) with mortality (rates). Although they sound the
same, they are different. While morbidity rates refer to the frequency of disease and illness in
a certain area, the mortality rate is used to describe the frequency of death in a population.
Mortality is the direct result of a condition or illness.
1.7: NUTRITIONAL ASSESSMENT
Nutritional status is the condition of health of the individual as influenced by the
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utilization of the nutrients. It can be determined by the correlation of information obtained

through medical and dietary history, thorough physical examination, and laboratory
investigation.
A nutritional assessment is an in-depth evaluation of both objective and subjective

data related to an individual's food and nutrient intake, lifestyle, and medical history. Once
the data on an individual is collected and organized, the practitioner can assess and evaluate
the nutritional status of that person. The assessment leads to a plan of care, or intervention,
designed to help the individual either maintain the assessed status or attain a healthier status.
Nutritional assessment aids in identifying:

a. Under Nutrition
b. Over Nutrition
c. Nutritional deficiencies
d. Individuals at the risk of developing malnutrition
e. Individuals at the risk of developing nutritionally related diseases
f. The resources are available to assist them to overcome nutritional problems.
1.7.1: NUTRITIONAL ASSESSMENT TECHNIQUES

Nutritional assessment is a comprehensive process that combines objective
measurements, a focused history, physical examination, and clinical judgment to decide a
patient's nutritional status. In multidisciplinary care, the various components of the nutritional
assessment may be divided among several disciplines or may be carried out by a single
individual. Registered dieticians are frequently the most experienced in nutritional
assessment but their availability may be limited in some healthcare environments such as
primary care or long-term facilities.
The nutritional status can be assessed by the following methods:

I. Direct Methods:
a) Nutritional Anthropometry
b) Clinical Examination
c) Biochemical tests and
d) Biophysical methods.
II. Indirect Methods:
a) Vital statistics of the community
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b) Assessment of socio-economic status and

c) Diet surveys
The above methods will be discussed in the separate unit in detail.
1.8: NUTRITIONAL SCREENING
In most healthcare settings, the nutritional assessment takes place in two steps; an
initial nutritional screening followed by a more formal nutritional assessment when
indicated. Routine history and physical examinations incorporate many components for
nutritional screening such as height, weight, blood pressure, blood glucose levels, and lipid
profile. In addition, primary care also includes screening for cancer and cancer and
osteoporosis, conditions in which nutrition or body weight plays a prominent role.
The Joint Commission also requires that nutritional screening be performed for
patients in all types of healthcare settings. The screening process assigns a level of
nutritional risk to patients based on their answers to a series of simple questions and helps
prioritize intervention for patients with the most urgent need for nutritional support.
Nutritional screening should be repeated at regular intervals, or whenever there is a change
in clinical status.
1.9: NUTRITION MONITOR
Nutrition monitor or surveillance is a system established to continuously monitor the

dietary intake and nutritional status of a population or selected population groups using a
variety of data collection methods whose ultimate goal is to lead to policy formulation and
action planning. Continuous monitoring varies among countries such that annual, bi-annual,
or other data-collection timeframes are determined by the funding and commitment of
national governments. Increasingly, countries have come to recognize the need to collect
dietary information systematically to make science-based policy decisions related to diet and
health. The term ‘nutrition monitoring’ is often used in addition to or interchangeably with
‘nutrition surveillance’ and is defined as surveillance that is carried out on selected
individuals. In this article, the term nutrition surveillance is used to include all data collection
methods that are described.
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The information obtained through nutrition surveillance is used for three broad
purposes: policy development, nutrition research, and monitoring. As Figure 2 illustrates,
there are strong interrelationships between these three purposes. Specifically, the information
generated by nutrition surveillance activities is used to describe the nutritional status of the
population and identify population groups at high nutrition risk. Programs are then targeted to
those in need.
The efficacy of the programs is assessed and nutrition policy is developed. Trends in
health status and food intake are monitored and food supply needs are estimated. Also,
linkages between food consumption, nutritional status, and health status are examined. For
example, normative data collected from surveys in the United States have been used to
develop new growth charts, released in 2000, to monitor the nutritional status and health of
children. Similarly, the World Health Organization, using international data, is also in the
process of developing new international growth charts. Monitoring trends in child growth
helps to identify populations in need, evaluate nutritional and health interventions, and raise
political awareness of nutritional problems.
Figure-2, Relationships among nutrition policymaking, nutrition research, and

nutrition monitoring.
Source: US Department of Health and Human Services/US Department of Agriculture (1993) Ten-
year comprehensive plan for the National Nutrition Monitoring and Related Research Program. Federal
Register 58: 32752–32806).
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1.10: MALNUTRITION
Malnutrition as defined by World Health Organisation (WHO) is a pathological state

resulting from a relative or absolute deficiency or excess of one or more essential nutrients,
this state being clinically manifested or detected only by biochemical, anthropometric, or
physiological tests.
Four forms can be distinguished:
a. Undernutrition – the pathological state resulting from the consumption of an

inadequate quantity of food over an extended period.
b. Marasmus is synonymous with severe undernutrition. Starvation implies the total
elimination of food and hence the rapid development of undernutrition and marasmus.
c. Specific deficiency – the pathological state resulting from a relative or absolute lack of
an individual nutrient.
d. Overnutrition – the pathological state resulting from a disproportion of essential
nutrients with or without the absolute deficiency of any nutrient as determined by the
requirement of a balanced diet.
Malnutrition is a major problem in developing countries like India due to the
widespread prevalence of poverty and associated problems. Malnutrition mainly results in
micronutrient deficiencies. The most common ones are vitamin A deficiency, iodine
deficiency, and iron deficiency. These are commonly seen among the vulnerable sections of
the population such as children, women of childbearing age, and lactating mothers.
Malnutrition among children can result in growth retardation. Undernutrition during
pregnancy affects the overall growth and development of the fetus. Realizing the harmful
effects of these deficiency disorders the government of India has started various nutrition
intervention programs to combat the problem of malnutrition.
Malnutrition occurs when an individual gets too few or too many nutrients, resulting
in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein,
and other nutrients" which adversely affects the body's tissues and form. Malnutrition is a
KSOU, Mysuru. 17
category of diseases that includes undernutrition and overnutrition. Undernutrition is a lack of

nutrients, which can result in stunted growth, wasting, and being underweight. A surplus of
nutrients causes overnutrition, which can result in obesity. In some developing countries,
overnutrition in the form of obesity is beginning to appear within the same communities as
undernutrition.
The relationship between malnutrition and nutrition assessment is critical. Any

elements that influence the development of malnutrition and the manifestations that result
should both comprise the steps of assessment and provide reliable identifiers for nutrition
screening. Solidifying a transparent definition of the malnourished state is vital to
understanding what and why specific signs and symptoms are assessed
1.11: UNDERNUTRITION
Undernutrition denotes insufficient intake of energy and nutrients to meet an

individual's needs to maintain good health. In most literature, undernutrition is used
synonymously with malnutrition. In the strictest sense, malnutrition denotes both
undernutrition and overnutrition. To overcome this, terms such as protein-energy
malnutrition, specific micronutrient deficiencies as well as other descriptive names such as
kwashiorkor and marasmus have been used. However, since protein energy malnutrition does
not exist in isolation from specific micronutrient deficiencies, neutral terms such as
undernutrition are encouraged because they encompass both protein-energy undernutrition as
well as micronutrient deficiencies. Similarly, overnutrition is used when there is an excess
intake of macronutrients and micronutrients. In the following pages, undernutrition and
malnutrition will be used interchangeably. Undernutrition will be discussed in terms of
protein-energy undernutrition and those specific micronutrient deficiencies which are
considered of public health significance in the community.
“Undernutrition is defined as insufficient intake of energy and nutrients to meet an

individual’s needs to maintain good health”.
Distribution of Undernutrition:
Measures of undernutrition:
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There are several indicators used to measure nutritional status. These include body
composition, clinical signs of deficiency, physical function, biochemical compounds,
metabolic processes, or dietary intake. The choice of which of these indicators is used is
dependent on the question being asked. In clinical settings, it is common to use a combination
of qualitative and quantitative descriptions of undernutrition e.g. marasmus and kwashiorkor
while in community studies of protein-energy undernutrition, the body size is widely used
because it is readily measurable and is a sensitive indicator of nutritional status and health.
However, for specific nutrient deficiencies, other indicators are used. For example, serum
retinol level, a biochemical measure, can be used to measure vitamin A deficiency and a
clinical feature e.g. xerophthalmia can also be used as a measure of vitamin A deficiency. The
commonly used anthropometric measures are weight and length (height) in combination with
age and sex. These measurements are used to construct indices and indicators** that are used
to describe the nutritional status of individuals or populations. Other measures of body
composition that are used include various body circumferences (mid-upper arm, head, chest,
abdomen, etc) and skin folds (biceps, triceps, sub-scapular, etc).
Three basic indices are used in childhood: weight for age Z score (WAZ),
length/height for age Z score (LAZ / HAZ), and weight for length/height Z score (WLZ /
WHZ).
 Weight for age: defined as a weight of a child relative to the weight of a child of the
same age in a reference population, expressed either as a Z score or a percentage relative
to the median of the reference population. Qualitatively children who have low weight for
age are described as being 'underweight’.
 Height for age (/ length for age): defined as the height or length of a child relative to the
length or height of a child of the same age in a reference population, expressed either as a
Z score or a percentage relative to the median of the reference population. Qualitatively
children who have low height for their age are described as being 'stunted'.
 Weight for height (/ weight for length): defined as the weight of a child relative to the
weight of a child of the same height or length in a reference population, expressed either
as a Z score''' or a percentage relative to the median of the reference population.
Qualitatively children who have low weight for height are described as being 'wasted'.
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Wasting is also sometimes called global undernutrition or global acute malnutrition

(GAM).
Incidence of undernutrition:
Primary malnutrition is usually a disease of the dependent and the vulnerable that rely
on others for their nutriture while secondary undernutrition accompanies any disease which
disturbs appetite, digestion, absorption, or utilization of nutrients. The vulnerable groups
include children in utero and within the first 5 years of life, adolescents, pregnant/lactating
women, and the elderly. Because children are completely dependent on others for their
nutriture they are especially vulnerable.
Risk factors for undernutrition:
In the development of undernutrition, the starting point is the reduction in dietary
intake. This can be due to psychiatric illness, anorexia associated with infection, liver disease,
neoplasia, drug interaction, nutrient deficiency, famine or starvation, upper intestinal disease,
mal-absorption, or other losses from the body. This reduced dietary intake in turn leads to
reduced mass, reduced requirement, reduced work, physiologic and metabolic changes,
changes in body composition, and loss of tissue reserve. The defects become self-reinforcing
in vicious cycles leading to the development of frank undernutrition and ultimately death. An
example of such a vicious cycle is illustrated in the figure.
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Figure- 3: Undernutrition – infection vicious cycle.

Source: State of the World’s Children 1998, UNICEF 1998.
Impact of undernutrition
• Strongly associated with risk of mortality such that it is directly and indirectly with 50% of all
developingcountry childhood mortality
• Contributes about a quarter of the total global burden of disease as measured by Disability-
adjusted life years (DALYs).
• Significantly affects cognition and development and in turn economic and social development
of countries
• Implicated in etiology of adult chronic diseases (Foetal Origins Hypothesis)
Prevention:
Several strategies have been employed for the prevention of undernutrition and they
range from specific interventions aimed at specific determinants to general interventions
aimed at a broad range of determinants. As highlighted in the sections on risk factors and
consequences, interventions targeting undernutrition are unlikely to work if they are targeting
single determinants. Specific nutrition deficiencies are likely to cluster in the same individuals
and communities such that only when interventions are integrated are they likely to work. The
interventions range from specific nutritional or non-nutritional interventions targeting a
specific deficiency to broad interventions targeting several deficiencies. The success of these
interventions is debatable as there is a paucity of very good studies examining their efficacy.
Below are some interventions which have shown some promise.
 Dietary supplementation during pregnancy
 Promotion of exclusive breastfeeding
 Improving complementary feeding
 Supplementary feeding
 Food fortification
 School feeding and health programs
1.12: OVERNUTRITION
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Overnutrition happens when your prolonged consumption of more nutrients (or

nutrients) than the body needs every day can lead to overnutrition. While many people think
malnutrition means a lack of nutrients, overconsumption is also considered malnutrition
because it has negative health consequences. In the short run, over-nutrition may cause no
signs or symptoms. But keep it up and some nutrients may increase to toxic amounts, which
can lead to serious disease. Iron overload, for example, can result in liver failure, and too
much vitamin A can have negative effects, particularly in children. The most common type of
overnutrition – excess intake of energy-yielding nutrients–is a principal cause of obesity. In
the long run, an overweight condition can lead to serious diseases, such as certain forms of
diabetes and cancer
Macronutrient Overnutrition:
Consuming too many calories (or energy) will cause you to gain weight over time
unless you increase your physical activity. It doesn't matter if those extra calories come from
macronutrients (fat, carbohydrates, or protein), because the body takes whatever it doesn't
need and stores it as fat.
Energy overnutrition is common in developed countries. Sometimes, people with this
type of overnutrition may also experience micronutrient undernutrition if the foods they eat
are high in calories but low in micronutrients.
Overnutrition often leads to overweight or obesity, which are risk factors for
cardiovascular disease, certain forms of cancer, and type -2 diabetes.
Micronutrient Overnutrition:
Micronutrient overnutrition occurs when you consume too much of a certain nutrient.
It's possible to get too much of most vitamins or minerals. Usually, this happens when you
take megadoses of dietary supplements. Getting too much of any micronutrient from food is
rare.
Micronutrient overnutrition can cause acute poisoning, such as taking too many iron
pills at once. It can also be chronic if you take large doses of a particular vitamin (such as
vitamin B6) over several weeks or months.
The Institute of Medicine has established tolerable upper limits for most
micronutrients, but the best way to avoid this type of overnutrition is to stay away from high
doses of dietary supplements unless directed by your healthcare provider.
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1.13: SUMMARY
 A community is a specific group of people who share common characteristics, e.g. a
common language, exposure to similar conditions, common lifestyle, or the same
health problem.
 Nutrition is defined as a science concerned with the role of food and nutrients in the
maintenance of health.
 Community nutrition is the science related to the practical application of nutritional
knowledge in the field to identify and solve nutritional problems of population groups
in the community.
 The term demography is made up of two words: “Demos”, which means
“population”, and “-graphy”, which means “describe.” One can then say that
demography is the science that researches and describes a population.
 Health statistics are numbers that summarize information related to health.
Researchers and experts from government, private, and non-profit agencies and
organizations collect health statistics.
 Mortality is defined as the demographic event of death. Mortality rate or death rate is
a measure of the number of deaths (in general, or due to a specific cause) in a
particular population, scaled to the size of that population, per unit of time.
 Morbidity rate refers to the rate at which a disease or illness occurs in a population
and can be used to determine the health of a population and its healthcare needs.
 A nutritional assessment is an in-depth evaluation of both objective and subjective
data related to an individual's food and nutrient intake, lifestyle, and medical history.
 In most healthcare settings, the nutritional assessment takes place in two steps; an
initial nutritional screening followed by a more formal nutritional assessment when
indicated.
 Nutrition monitor or surveillance is a system established to continuously monitor the
dietary intake and nutritional status of a population
 Malnutrition is a major problem in developing countries like India due to the
widespread prevalence of poverty and associated problems. Malnutrition mainly
results in micronutrient deficiencies.
 Malnutrition is a category of diseases that includes undernutrition and overnutrition.
Undernutrition is a lack of nutrients, which can result in stunted growth, wasting, and
KSOU, Mysuru. 23
being underweight. A surplus of nutrients causes overnutrition, which can result in

obesity.
 Undernutrition denotes insufficient intake of energy and nutrients to meet an
individual’s needs to maintain good health.
 Overnutrition happens when your prolonged consumption of more nutrients (or
nutrients) than the body needs every day can lead to overnutrition.

1. Define community nutrition.
2. What is demography?
3. What are the fundamentals aspects of demography?
4. List the health statistics modules.
5. Define mortality rate.
6. How do you measure the mortality rate?

7. Write the types of nutritional assessment.
8. How the nutritional surveillance system works.
9. Mention the forms of malnutrition.
10. What are the measures of undernutrition?
11. Write the risk factors for undernutrition.
12. Discuss types of overnutrition.
1.16: GLOSSARY
Evidence-Based Medicine (EBM): Evidence-based medicine is "the conscientious, explicit

and judicious use of current best evidence in making decisions about the care of
individual patients".
Mortality: Mortality is defined as the demographic event of death.
Crude Death Rate: The crude death rate is calculated by dividing the number of registered
deaths in a year by the mid-year population for the same year.
Age Specific Death Rates (ASDR): The age-specific death rates are calculated from deaths
and populations both specific to each age (or age group) of the population.
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Neo-natal Mortality: The mortality of live-born before completing four weeks or 28 days of
life is known as neonatal mortality.
Post-neo-natal Mortality rate: The mortality of live-born after 28 days after birth, but
before reaching the age of one year is called post- neo-natal mortality.
Perinatal Mortality rate: Deaths between the periods of seven months of gestation
(stillbirth) to the first week of life.
Infant Mortality rate: The mortality of life born under one year of age is known as infant
mortality.
Maternal Mortality rate: Maternal death is defined as, “the death of a woman while
pregnant or within 42 days of termination of pregnancy.
Nutritional status: Nutritional status is the condition of health of the individual as
influenced by the utilization of the nutrients.
Nutritional screening: The screening process assigns a level of nutritional risk to patients
based on their answers to a series of simple questions and helps prioritize
intervention for patients with the most urgent need for nutritional support.
Nutrition monitor or surveillance: it is a system established to continuously monitor the
dietary intake and nutritional status of a population.
Malnutrition: Specifically, it is "a deficiency, excess, or imbalance of energy, protein, and

other nutrients" which adversely affects the body's tissues and form.
Undernutrition: the state of insufficient intake of energy and nutrients to meet an

individual’s recommended needs to maintain good health.
Overnutrition: it will happen when people's prolonged consumption of more nutrients (or
nutrients) than the body needs every day can lead to overnutrition.
1.17: REFERENCES:
1. Centers for Disease Control and Prevention. "Lesson 3: Measures of Risk Section 2:
Morbidity Frequency Measures."
2. National Cancer Institute. "Morbidity."
3. Trinity Medical Group. "Acute Conditions.
4. Shryock Henry S, Jacob S. Siegel and Associates, 1980: The Methods and Materials
of Demography, Vol II,
5. Pathak K.B. and Ram F., 1998: Technique of Demographic Analysis, Himalaya
Publishing House, Mumbai
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6. Schoenbach, V.J. 1999. Standardization of Rates and Ratios: Concepts and basic
methods for deriving measures that are comparable across populations that differ in
age and other demographic variables. Available online at:
http://www.epidemiolog.net/evolving/Standardization.pdf
7. Government of India (2015), Manual on Health Statistics in India, Central Statistical
Office, Ministry of Statistics and Programme Implementation, New Delhi.

1. Prakasam, C.P. 2017. Materials Submitted for Mortality Paper, Population Studies,
UGC e-pathshala, School of Development Studies, Tata Institute of Social Sciences.
2. Waterlow JC (1976): Classification and definition of protein energy malnutrition.
WHO Monograph Series no 68. World Health Organisation, Geneva.
3. Tomkins AM, Watson F (1989): Malnutrition and infection. A review. Advisory
Committee on Co-ordination/Subcommittee on Nutrition, World Health Organisation,
Geneva.
4. Jason JM, Nieberg P and Marks JS (1984): Mortality and infectious disease associated
with infant feeding practices in developing countries. Pediatrics 74(Suppl):702-727.
5. Pelletier D, Frongillo EA, Schroeder D, and Habicht JP (1994): The effects of
malnutrition on child mortality in developing countries. Bull WHO 1995; 7(4):443-
448.
6. Martorell R, Habicht JP, Yarbrough C, Lechtig A, Klein E and Western KA (1975):
Acute morbidity and physical growth in rural Guatemalan children. Am J Dis Child
129:1296-1301.
7. Morley D, Bricknell J, and Woodland M (1968): Factors influencing the growth and
nutritional status of infants and young children in a Nigerian village. Trans R Soc
Trop Med Hyg 62: 165-95.
----------***********------------
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UNIT-2 ASSESSMENT OF NUTRITIONAL STATUS IN COMMUNITY-

ANTHROPOMETRY ASSESSMENT
2.0: OBJECTIVES
2.1: INTRODUCTIONS
2.2 NUTRITIONAL STATUS – CONCEPT AND IMPORTANCE OF ASSESSMENT
2.3: NUTRITIONAL ASSESSMENT TECHNIQUE
2.4: ANTHROPOMETRIC MEASUREMENT
2.4.1: INFANTS AND CHILDREN

2.4.2: ADOLESCENTS
2.4.3: ADULTS
2.4.4: ELDERLY
2.5: ADVANTAGES AND DISADVANTAGES OF NUTRITIONAL
ANTHROPOMETRY
2.6: ANTHROPOMETRIC MEASUREMENTS USING DIFFERENT EQUIPMENT
2.6.1: MEASURING BODY WEIGHT

2.6.2: HEIGHT MEASUREMENT
2.6.3: WAIST CIRCUMFERENCE MEASUREMENT
2.6.4: HIP CIRCUMFERENCE MEASUREMENT
2.6.5: MID-UPPER ARM CIRCUMFERENCE MEASUREMENT
2.6.6: FAT FOLD AT TRICEPS
2.7: SUMMARY
2.8: GLOSSARY
2.10: CHECK YOUR PROGRESS -2
2.11: REFERENCES
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2.0: OBJECTIVES
After studied this unit you will able be to:
 Know the role of anthropometric measurement in assessing the nutritional status

of the individual.
 Understand the advantages and disadvantages of nutritional anthropometry.
 Describe techniques used in the anthropometric assessment.
 Describe anthropometric measurements using different equipment.
2.1: INTRODUCTION
Nutritional assessment is the interpretation of anthropometric, biochemical

(laboratory), clinical and dietary data to determine whether a person or groups of people are
well nourished or malnourished (over-nourished or under-nourished). A nutrition assessment
includes computerized food intake analysis, clinical nutrition body composition assessment
(bioelectrical impedance), laboratory blood test if applicable anthropometrics, and review of
medications, lifestyle, and fitness indicators. It aims at discovering facts and guiding action
intended to improve nutrition and health. Nutritional assessment can be categorized as direct
assessment and indirect assessment.
In direct assessment body measurements, clinical examination, biochemical tests, and
dietary intake are considered to evaluate the nutritional status. Under the indirect method of
assessment, vital statistics like mortality, morbidity rates, and various ecological factors like
food consumption practices, socioeconomic factors, and health care facilities/ practices are
considered.
2.2: NUTRITIONAL SCREENING, NUTRITIONAL STATUS – CONCEPT AND

IMPORTANCE OF ASSESSMENT
In most healthcare settings, nutritional assessment takes place in two steps; an initial
nutritional screening followed by a more formal nutritional assessment when indicated.
Routine history and physical examinations incorporate many components for nutritional
screening such as height, weight, blood pressure, blood glucose levels and lipid profile. In
addition, primary care also includes screening for cancer and cancer and osteoporosis,
conditions in which nutrition or body weight plays a prominent role.
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The Joint Commission also requires that nutritional screening be performed for
patients in all types of healthcare settings. The screening process assigns a level of nutritional
risk to patients based on their answers to a series of simple questions and helps prioritize
intervention for patients with the most urgent need for nutritional support. Nutritional
screening should be repeated at regular intervals, or whenever there is a change in clinical
status.
Nutritional status is the state of health that is affected by the intake of food and
utilization of nutrients in the body. It indicates whether a person is malnourished or normal.
Nutritional status is likely to be good when a person consumes a diet that is sufficient to meet
his needs to function optimally; while decreased or excessive food intake and inefficient
utilization of nutrients may result in a person having a poor nutritional status. The spectrum
of nutritional status spreads from severe undernutrition and nutrient deficiencies to obesity.
Nutritional status is influenced by multiple interrelated factors which may be categorized as
internal or external factors. Internal factors include heredity, ethnicity, age, sex, food
behavior, physical activity, and disease; while social, cultural, economic situation, food
availability, access, safety, etc. are the external factors. Some internal factors such as heredity
and ethnicity that have an important influence on some of the health parameters such as an
individual’s height and weight cannot be modified.
For example, Asians are normally shorter than their western counterparts. While some
other modifiable internal, as well as external factors such as food behavior, lifestyle practices,
economic condition, religious and cultural practices, etc., may either deteriorate or improve
the nutritional status. However, it is essential to first assess nutritional status so that it can be
modified as desired.
Assessment of the nutritional status of individuals and communities has several
advantages; some of which have been enumerated as follows:
 For individuals:
 It helps them know their state of nutrition/ malnutrition and take appropriate measures
to improve it. It helps them decide what to eat, what to avoid etc.
 It helps them identify their health problem - whether it is due to a deficiency, excess,
or imbalance of nutrients.
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 For communities
 It helps to identify groups in the community who are malnourished or who are at risk
of becoming malnourished.
 It helps to determine the various factors in the community that contribute to
malnutrition.
 These may be factors such as state of poverty, religious beliefs and cultural practices,
availability of health and education-related services, geographical and climatic
conditions prevailing in the area that affect food availability, etc.
 It helps to know the state of food and nutrition security in the community. This is
indicated by how much food is available to the community members, whether it is
being distributed properly among all members in required amounts, and whether
people are suffering from diseases that can affect the effective utilization of the food
consumed.
 It helps to estimate the nutritional problems of the community – whether the entire
community or different genders or age groups are suffering from some specific
nutrition-related problems. For example, one can know whether the prevalence of
iron-deficiency anemia is higher among adolescent females and pregnant women or
whether it is the same in females and males of all age groups.
 It helps the government and other agencies to allocate their resources properly and
plan suitable nutrition programs for the communities to improve their nutrition
situation and reduce mortality and morbidity related to malnutrition.
 It helps to evaluate the effectiveness of the nutrition programs and interventions
initiated for combating malnutrition in the communities.
Now that you know the importance of assessing nutritional status, let us learn about the
techniques and different methods that can be used for nutritional assessment.
2.3: NUTRITIONAL ASSESSMENT TECHNIQUES
Nutritional assessment is a comprehensive process that combines objective

measurements, a focused history and physical examination, and clinical judgment to decide a
patient's nutritional status. In multidisciplinary care, the various components of the nutritional
assessment may be divided among several disciplines or may be carried out by a single
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individual. Registered dieticians are frequently the most experienced in nutritional

assessment but their availability may be limited in some healthcare environments such as
primary care or long-term facilities.
There are several methods and techniques of assessment of nutritional status having
their advantages and limitations. These have to be chosen with care. No single method may
be ideal or most suitable for nutritional assessment. The method of nutritional assessment
should be chosen depending on the number of people to be assessed, the objective of the
assessment, and the resources available. Most often, several methods may be used together to
get a clear picture of the nutritional status of individuals. Nutritional assessment may be done
using direct or indirect methods. Direct methods deal with the individual and measure certain
indicators such as weight, height, clinical signs, food and nutrient intake, nutrient levels in
blood and urine, etc. The direct methods of nutritional assessment can be classified as the
‘ABCD’ methods which are: Anthropometry, Biochemical/biophysical, Clinical methods,
and Dietary methods.
Figure: 1 ABCD method of nutritional assessment.
2.4 ANTHROPOMETRIC MEASUREMENTS
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The term 'Nutritional Anthropometry" is used for body size measurements, which
provides an objective indication of the nutritional status. Anthropometric assessment is one of
the most versatile tools for measuring nutritional status. It is based on the concept that an
appropriate body measurement reflects any morphological variation occurring due to a
significant functional physiological change.
2.4.1: Infants and Children

It is universally accepted that anthropometry is the most useful tool for assessing the
nutritional status and the risk of poor health and survival of infants and young children.
Anthropometry involves obtaining physical measurements of an individual and relating them
to a standard. Three anthropometric indices commonly used to assess children are weight-for-
age (W/A), height-for-age (H/A), and weight-for-height (W/H). Besides weight and height,
skinfold thickness is particularly useful being a direct indicator of calorie status, while height
may be influenced more importantly by protein status.
In infants and children under five years of age, assessment of growth has been the
single most important measurement that best defines their nutritional status. Disturbances in
nutrition as a result of inadequacy of food intake, severe and repeated infections, or a
combination of both, operating very often as a vicious spiral, invariably affect the growth of a
child. These adverse conditions are closely linked to the general standard of living and the
population's ability to meet its basic needs for nutritious food, safe water, good housing, and
acceptable levels of environmental sanitation, ready and easy access to health care.
Assessment of the nutritional status of the child by the use of nutritional anthropometric
indicators of growth has thus been used not only to provide information on the nutritional and
health status of children but also as an indirect measure of the quality of life of the entire
community or population, and thereby as an indicator of the nutritional status and adequacy
of food of all members of that community. There are now, however, growing doubts whether
estimates of undernutrition based on nutritional anthropometric survey data in children alone
(without any information about the adults in the community) necessarily reflect the overall
nutritional status and the adequacy of food availability within the entire community (FAO,
1994).
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2.4.2: Adolescents:
Adolescents comprise a significant proportion of the world's population; some
estimates put the number of youth at over 30 percent of the world population. The proportion
of adolescents within a population group is also rising relative to other age groups, and an
overwhelming proportion of young adolescents live in developing countries. An increase in
height, as well as weight, occurs during the period. About 25 percent of an individual's
attained height is achieved during adolescence as a result of the adolescent growth spurt that
marks the end of the growth in height. Variations in adolescents' body size and the timing of
maturational events are determined genetically in populations whose environment allows full
expression of the genotype. Where this is limited by environmental constraints, including
nutrition, the observed growth and maturation during adolescence reflect environmental
rather than inherited potential. It is now clear that growth differences among groups are also
related to nutritional status, socioeconomic and other factors.
Growth in adolescence may be limited by prolonged undernutrition, infections, and

chronic disease. Stunting or short stature in adolescence is not only indicative of past
undernutrition during childhood but also may be a cumulative indicator of nutritional status
during adolescence. Stunting among adolescents reflects increased health risks, particularly
among females who would also tend to have a small pelvis, leading possibly to obstructed
labor during childbirth. A gain in weight is also considered during the adolescent years with
an increase in both muscle and fat. Girls tend to gain relatively more fat, while boys gain
relatively more muscle. Undernutrition in girls during adolescence is characterized by a low
weight, which may result in poor pregnancy outcomes, particularly low birth weight.
Undernutrition also may limit school achievement and work productivity in later years. There
is emerging evidence that stunted individuals are at increased risk of overweight and obesity
when food availability increases and lifestyles change (Popkin, Richards, and Montiero,
1996).
The diagnostic criterion for defining stunting in adolescents is a height-for-age less
than the third percentile of the NCHS/WHO reference data or less than a -2 Z-score.
Undernutrition or thinness in adolescence is indicated by a body mass index (BMI, weight/
KSOU, Mysuru. 33
(height) 2) less than the percentile of the NCHS/WHO reference data (WHO, 1995). A BMI
greater than the 85th percentile in adolescence is indicative of a risk of being overweight.
2.4.3: Adults:
The lack of a true definition for the assessment of adult’s undernutrition is due to the
difficulty in establishing satisfactory reference standards for normality and in delineating cut-
offs to help distinguish between well-nourished and undernourished adults in population
groups. A chronic state of undernutrition in the adult has its cost in terms of risk to health and
impairment of function, which may include a lowered work capacity, a reduced ability to
sustain economically productive work or even socially desirable physical activities, and
possibly an impaired immune function with a predisposition to repeated infections (FAO,
1994).
Body Mass Index (BMI) is a person's weight in kilograms divided by the square of
height in meters. BMI is considered to be the most suitable, objective anthropometric
indicator of the nutritional status of the adult. It was chosen because this anthropometric
indicator, derived from measures of weight and height of individuals of both sexes, is
consistently and highly correlated with body weight (or energy stores within the body) and is
relatively independent of the height of the adult. While a BMI <18.5 is considered the cut-off
for the diagnosis of chronic undernutrition in adults, a series of cut-offs are provided to
delineate the degrees of severity of undernutrition. The lower limit of normality is based on
the BMI of patients with anorexia nervosa and a large sample of healthy, young British
soldiers. Concerns that lean but healthy and very' active adults may be wrongly categorized
or misclassified as undernourished lead initially to the inclusion of energy turnover based on
the basal metabolic rate as an additional criterion. However, BMI alone is now accepted as
the anthropometric indicator of choice for chronic undernutrition in the adult, as the
probability of misclassifying nutritional status based on the BMI is considered to be very
small. This indicator has similar advantages over weight-for-height in children in that it
reflects the degree of severity of undernutrition and also can be used to assess overnutrition in
adults, by enabling the classification of overweight and obese individuals in a population.
BMI is thus a simple but objective anthropometric indicator of the nutritional status of
the adult population and is closely related to food consumption and the prevalence of
KSOU, Mysuru. 34
inadequacy of food in the community. Data on BMI are relatively easy to collect and
inexpensive to analyze. The collection of data on heights and weights of adults from which
BMI is easily derived can be readily incorporated into regional and national surveys being
conducted. BMI can be used for nutritional surveillance and for monitoring the effectiveness
of intervention programs and it also allows for interregional and inter-country comparisons
over seasons, years, or decades.
Table -1 Body mass Index Classification
2.4.4: Elderly
Adults 60 years of age and older represent the fastest-growing segment of the
population throughout the world. A decline in height with age is well documented in the
elderly, and a weight reduction also occurs with an increase in age, although the pattern of
weight change is quite different from that of height and varies with the sex of the individual.
The use of anthropometry is relatively recent in the elderly, and the anthropometric index of
choice is the BMI, as in the case of non-elderly adults. Thus, height, weight, and BMI are
good indicators of nutritional status and the risk of morbidity and mortality in the elderly
KSOU, Mysuru. 35
population. Height can be difficult to measure in the elderly as a result of increasing spinal
curvature with age; there are no guidelines regarding the degree of spinal curvature that
would invalidate the measurement of height. It can be estimated from knee height or arm
span, although WHO (1995) recommends knee height as being the more satisfactory of the
two. The estimated height can then be used to derive BMI using the recommended cut-off
points of <18.5 for under-weight and >25 for overweight (BMI,18.5- 22.9 is the Normal
range for Asians, Table -1) the same as those used for non-elderly adults.
2.5: ADVANTAGES AND DISADVANTAGES OF NUTRITIONAL ANTHROPOMETRY
Advantages of Nutritional Anthropometry

 Methods are precise and accurate, provided standardized techniques are used.
 Procedures use simple, safe, and non-invasive techniques.
 The equipment required is inexpensive, portable, and durable and can be made or
purchased locally.
 Relatively unskilled personnel can perform measurement procedures.
 Information is generated on past nutritional history.
 Methods can be used to quantify the degree of undernutrition (or overnutrition) and
provide a continuum of assessment from under-to-over nutrition.
 Methods are suitable for large sample sizes such as representative population samples.
 Methods can be used to monitor and evaluate changes in nutritional status over time,
seasons, generations, etc.
Limitations in Nutritional Anthropometry

 The relative insensitivity to detect changes in nutritional status following inadequacy of
food over short periods.
 The inability to distinguish the effect of specific nutrient deficiencies (e.g. zinc
deficiency) that affect growth in children from that due to inadequacy of food in
general.
 The inability to pinpoint the principal casualty of undernutrition, as the poor nutritional
status may be the result of factors such as repeated insults owing to infections and
poor care in children.
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(Source: as given by Shetty, 2002)
2.6: ANTHROPOMETRIC MEASUREMENTS USING DIFFERENT EQUIPMENT
For anthropometric measurements (weight, height, waist, and hip circumference) the
following equipment is needed:
 Balanced beam scale;
 portable/wall-mounted stadiometer with movable headpiece, or measuring rod,
typically mounted on balanced beam scales;
 Flexible but non-stretchable measuring tape or insertion tape;
 Full body-length mirror with 10 cm x 10 cm grid lines;
 carpenter's level;
 Several calibrated weights (e.g. 10 kg or 20 kg each) can be combined to give test
weights between 50 kg and 100 kg;
 Calibrated length rods of ISO cm and 200 cm.
MEASUREMENT PROCEDURES:
2.6.1 Measuring Body Weight:

Body weight is the most widely used simplest and very sensitive anthropometric
measurement for assessing nutritional status. It indicates body mass like water, mineral, fat,
protein, and bone. It gives the current nutritional status.
Instruments for measuring weight- spring balance, beam balance, and electronic balance.
In the case of infants, an infant-o-meter or a spring balance with an attached carry bag can
be used for weighing.
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Infant-o meter
Beam balance
Analog weighing scale
Figure- 2: Weighing Measurement Instruments
Care to be exercised for the use of balance: check for accuracy of the balance each time
before use. Standard weights measuring 10 and 20 kg are ideal or sandbags of known weights
can be used for the purpose. Set the instrument to '0' before starting.
Points to be considered for weighing: the person should empty his bladder, and should have
consumed food and drinks at least 1 ½ hour before. He or she should wear light clothes and
without shoes.
Setting up scale at the examination site
The scale should be placed on a hard-floor surface (not on a floor that is carpeted or
otherwise covered with soft material). If there is no such floor available, a hard wooden
platform should be placed under the scale. A carpenter's level should be used to verify that
the surface on which the scale is placed is horizontal.
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Calibration of scale
Calibration should occur at the beginning and end of each examining day.
The scale is balanced with both sliding weights at zero and the balance bar aligned. The scale
is checked using the standardized weights and calibration is corrected if the error is greater
than 0.2 kg. The results of the checking and the recalibrations are recorded in a log book.
Normal weighing procedure
1. The subjects are asked to remove their heavy outer garments (jacket, coat, trousers,
etc.) and shoes.
2. The subject has to stand in the center of the platform, weight is distributed evenly to
both feet. Standing off-center may affect the measurement.
3. For children, beam balance scales are used. The child is made to sit or lie down on the
balance and the weight is recorded nearest to grams.
Figure -3: Posture of the subject during the weight measurement

The weights are moved until the beam balances (the arrows are aligned).
2.6.2 Height measurement:
The height of an individual is influenced both by genetic and environmental factors.
The maximum growth potential of an individual is decided by hereditary factors, while the
environmental factors – the most being nutrition and morbidity, determine the extent of
exploitation of that genetic potential. Height is affected only by long-term nutritional
deprivation; it is considered an index of chronic and long-duration malnutrition. Height
should be measured in all participants, except wheelchair-bound individuals, persons who
have difficulty standing steady or straight.
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Setting up a stadiometer at the examination site

If the height is measured with the measuring rod attached to the balanced beam scale no
further set-up procedures are required, if the scale has been placed properly for weighing.
However, it should be verified that the upper part of the measuring rod is straight and vertical
(i.e. not bent or curved).
If the height is measured by a stadiometer, the height rule is taped vertically to the hard flat
wall surface with the base at floor level. The wall may not have baseboard molding. A
carpenter's level is used to check the vertical placement of the rule.
The floor surface next to the height rule must be hard. If no such floor is available, a hard
wooden platform should be placed under the base of the height rule. Using the carpenter's
level, the surface on which the height rule rests should be checked to be horizontal.
Calibration of height rule
At the beginning and end of each examination day, the height rule should be checked with
standardized rods and corrected if the error is greater than 2 mm. The results of the checking
and recalibrations are recorded in the logbook.
Figure – 4: Normal height measurement procedure
1. Participants are asked to remove their shoes, and hair ornaments.

2. The participant is asked to stand with his/her back to the height rule. The back of the
head, back, buttocks, calves, and heels should be touching the upright, feet together.
The participant is asked to look straight.
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Figure-5: Infantometer (Children's height measurement)

3. In children below 2 years of age recumbent length should be measured with an
infantometer the legs need to be held straight and firm with the feet touching the
sliding board.
4. The headpiece of the stadiometer or the sliding part of the measuring rod is lowered
so that the hair (if present) is pressed flat.
5. Height is recorded to the resolution of the height rule (i.e. nearest millimetre/half a
centimetre). If the participant is taller than the measurer, the measurer should stand on
a platform so that he/she can properly read the height rule.
2.6.3 Waist circumference measurement:
Setting up the place for the waist circumference measurement:

The full body-length mirror is placed against the wall or if the mirror stands on its
own feet next to the measurement place. Using the carpenter level, it should be verified that
grid lines on the mirror are horizontal.
Checking of tape:
The length of the measuring tape is checked with the calibrated length rod (usually the
150 cm one) at least once per month. If the measuring tape is stretched it should be replaced.
Position of waist circumference measurement:
Waist circumference should be measured at a level midway between the lower rib
margin and iliac crest with the tape all around the body in a horizontal position.
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Figure- 6: Position of waist and hip circumference measurement

Waist circumference measurement procedure:
1. Participants are asked to remove their clothes, except for light underwear. If this is not
possible, for example, due to cultural reasons, the alternative is to measure the
circumference of the subject without heavy outer garments and record this fact in the
data collection form. Tight clothing, including the belt, should be loosened and the
pockets empty.
2. The measurer should stand at the side of the participant to have a clear view of the
mirror.
3. Participants should be standing with their feet fairly close together (about 12-15 cm)
with their weight equally distributed to each leg. Participants are asked to breathe
normally; the reading of the measurement should be taken at the end of gentle
exhaling. This will prevent subjects from contracting their abdominal muscles or from
holding their breath.
4. The measuring tape is held firmly, ensuring its horizontal position. Use the grid lines
on the mirror to verify that the tape position is horizontal all around the waist. The
tape should be loose enough to allow the observer to place one finger between the
tape and the subject's body.
5. Measurements are recorded to the resolution of the tape (nearest millimeter/half a
centimeter).
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2.6.4 Hip circumference measurement:
Figure- 7: Position of hip circumference measurement

Hip circumference should be measured as the maximal circumference over the
buttocks. The grid lines on the mirror are used to verify that the tape position is horizontal all
around the body.
2.6. 5 Mid-upper arm circumference (MUAC):
Mid-upper arm circumference (MUAC) is a useful indicator of nutritional status. Poor
musculature and wasting are cardinal features of moderate and severe protein energy
malnutrition in early childhood. It indicates the muscular status of the individual. MUAC is
considered as most feasible and easy for any age and sex. It also determines the mortality
risk in children.
Figure-8: Measurement of Mid upper arm circumference
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Steps of MUAC measurement

1. Ask the mother to remove any clothing that covers the child's arm. If possible the
child should stand erect and sideways to the measurer.
2. Estimate the mid-point of the left arm.
3. Straighten the child's arm and wrap the tape around at the mid-point. Make sure that
the numbers are right side up. Make sure the tape is flat around the skin.
4. Inspect the tension of the tape on the child's arm. Make sure the tape has the proper
tension and is not too tight or too loose. Repeat any step as necessary.
5. When the tape is in the correct position and with correct tension on the arm, read and
call out the measurement to the nearest 0.1 cm.
6. Immediately record the measurement.
Mid-upper arm circumference is measured halfway between the acromion process of the
scapula and the tip of the elbow. It is an indicator of muscle development. It is more feasible
as it is simpler and easily accessible for any age and sex and is practical to measure. It is
useful in not only identifying malnutrition but also in determining the mortality risk in
children. Poor musculature and wasting are features of protein energy malnutrition in early
childhood.
2.6.6 Fat fold at Triceps:
In the body biceps and triceps make up a large majority of your arm
musculature. Biceps are always located in the front portion of the upper arm which provides
arm flection, while the triceps are found on the back of the upper arm and are responsible for
arm extension. The biceps and triceps are easily targeted by a variety of exercises.
Measuring body fat% using calipers
Figure- 9: measurement of skinfold thickness
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The skin fold calipers measure the thickness of a fold of your skin and its underlying
fat. By taking skin fold measurements at four specific sites on the body you can estimate the
body fat %.
When using the calipers first pinch the skin with your free hand and without releasing the
hand measure the skin fold with the calipers.
1. First, pinch the fold of the skin with the fingers of one hand.
2. Then apply the jaws of the caliper just next to the fingers and squeeze the calipers
using the "press" arm until the 2 arrows line up. Do not read the caliper
immediately but allow the jaws to settle into the fold for 2-3 seconds.
3. Then read the number on the scale. This is the skin fold thickness in millimeters.
4. Enter each of the 4 readings into the appropriate input fields. Enter your total
weight, your age group, and your gender, then click on the Calculate button
It is the most commonly measured fat fold. The measurement is made on the dorsal side
at the same midpoint where the mid-upper arm circumference is measured. The skin fold is
picked up between the thumb and the forefinger about one centimeter above the mid-point,
taking care not to include the underlying muscle. It should be measured carefully as the
thickness of the fat layers changes very rapidly over a relatively short distance. The
subcutaneous fat gets compressed if the caliper is kept for a longer time. The skin fold should
be held gently in the left hand while the measurements are taken.
2.7: SUMMARY:
 The principal aim of the nutritional assessment of a community is to map

out the magnitude and geographical distribution of malnutrition as a public
health problem and the first step in the formulation of a strategy to combat
malnutrition.
 Nutritional anthropometry provides information concerning the nutritional

profile of the community.
 It is concerned with measuring the variations of the physical dimension and the
gross composition of the human body at different ages.
 The most commonly used measurements in routine surveys are – body weight,
crown-heel length, mid-upper arm circumference, fat fold triceps, and head
and chest circumference (for infants only).
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 A combination of diet surveys and clinical and biochemical assessments with

anthropometric assessments will give the exact nutritional status of the
individuals or communities.
2.8: GLOSSARY:
Bioelectrical impedance: Bioelectrical impedance analysis (BIA) measures body

composition based on the rate at which an electrical current
travels through the body.
Nutritional Anthropometry: It is used as body size measurements, which provide an
objective indication of the nutritional status.
Calibration: To standardize (something, such as a measuring instrument) by determining the
deviation from a standard to ascertain the proper correction factors.
MUAC: Mid-upper arm circumference (MUAC) is a useful indicator of nutritional status.
Triceps: The triceps are found on the back of the upper arm and are responsible for arm
extension.
Body mass index: It is a person's weight in kilograms divided by the square of height in
meters. This uses your height and weight to work out if your weight is
healthy.
Ideal body weight: It is defined as weight for height at the lowest risk of mortality.
Malnutrition: Malnutrition refers to deficiencies, excesses, or imbalances in a person's

intake of energy and/or nutrients.
Metabolic syndrome: Metabolic syndrome is a cluster of conditions that occur together,

increasing your risk of heart disease, stroke, and type 2 diabetes.
Nutritional assessment: It is the systematic process of collecting and interpreting

information to make decisions about the nature and cause of
nutrition-related health issues that affect an individual.
Nutritional screening: It is a process used to quickly identify those who may be at risk of
malnutrition so that a full nutrition assessment and appropriate
nutrition intervention can be provided.
Infantometer: An instrument for measuring the size of young children.
Calipers: An instrument for measuring external or internal dimensions (measuring

thicknesses or distances between surfaces), having two hinged legs resembling a
pair of compasses and in-turned or out-turned points.
7. Define nutrition screening.
8. Name the types of nutritional assessment.
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9. Write the concept and importance of nutritional assessment.

10. Name the techniques used to assess the nutritional status.
11. What is Nutritional Anthropometry?
12. Mention the advantages and disadvantages of nutritional anthropometry.
13. Discuss the procedure for weight/ height..
2.10: CHECK YOUR PROGRESS -2
14. Define BMI?
15. Which instrument used to measure skinfold thickness?
16. What is Infantometer?
17. Write the position of waist and hip.
18. How do you measure MUAC.
19. Differentiate the biceps and triceps.
2.11: REFERENCES
1. Swaminathan, M. (1997), Essentials of Food and Nutrition, vol I Second edition,
BAPPCO, Bangalore p-p 107-111.
2. Bamji M. S, Prahlad Rao N and Vinodinireddy (2003). Textbook of Human Nutrition
(p-p 197201), New Delhi. Oxford & IBH Publishing Co. PVT. LTD
3. Srilakshmi., B,(2005), Nutrition Science (p,p 3-14), New Delhi. New Age
International (P) Limited.
4. Mahan, K. L., Stump E. S. (2012). Food and the Nutrition Care Process. (13thed)
USA: Saundus Elsevier. 8. Mary, M. Mary K.R. &Scott .A. S. (2008).Clinical
Nutrition for surgical patients. Jones&Barlett Publishers.
1. Swaminathan, M, (2007) Essentials of Food and Nutrition. An Advanced Textbook
Vol. I, the Bangalore Printing and Publishing Co. Ltd, Bangalore.
2. Srilakshmi., B, (2017), Nutrition Science, New Age International Publication, New
Delhi.
3. Bamji M.S, PrahladRao N, Reddy V (2019)Textbook of Human Nutrition, II Edition,
Oxford and PBH Publishing Co. Pvt. Ltd, New Delhi.
-------------------*********---------------------
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UNIT-3 BIOCHEMICAL ASSESSMENT OF NUTRITIONAL STATUS AND

CLINICAL ASSESSMENT
STRUCTURE:
3.0: OBJECTIVE
3.1: INTRODUCTION
3.2: BIOCHEMICAL ASSESSMENTS
3.3: BIOCHEMICAL TESTS
3.4: REFERENCE VALUES FOR BIOCHEMICAL TESTS
3.5: CLINICAL ASSESSMENT
3.6: FUNCTIONAL TESTS
3.7: SUMMARY
3.8: GLOSSARY
3.9: CHECK YOUR PROGRESS
3.10: CHECK YOUR PROGRESS-II
3.11: REFERENCES
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3.0: OBJECTIVES
After reading this unit, you will be able to:

 Discuss the different types of biochemical assessments.
 Know the reference ranges of biochemical parameters and compare them with the
observed values.
 Understand the clinical assessments.
3.1: INTRODUCTION
The Biochemical assessment is an important component of the nutrition care

process, which must be interpreted with other methods (i.e., physical findings, patient
history, and anthropometrics) for accuracy. Nutrient concentrations in plasma do not
reflect the amount of the substance stored in body pools and may be influenced by
disease, inflammation, and recent dietary intake. Fluid, electrolyte, and acid-base
imbalances can lead to serious complications, ranging from metabolic and
gastrointestinal problems to cardiovascular, respiratory, and neurological concerns,
each requiring careful evaluation, monitoring, and treatment. Lipid profile results can
be used to assess the risk of cardiovascular (elevated low-density lipoprotein, decreased
high-density/low-density lipoprotein ratio) and metabolic (elevated triglycerides)
disorders, as well as the risk of malnutrition (decreased cholesterol) in patients.
Deficiencies in iron, vitamin B12, and folate, and toxicities of copper and zinc can all
compromise red blood cell functioning and contribute to anemia.
In the field of nutrition, a major challenge is how to identify individuals and

or populations who have nutritional problems. Appropriate nutritional assessment can
provide the answer. The development of a nutritional deficiency state represents a
continuum from the early to late stages. Clinical assessment may readily detect the late
or severe stages of nutritional deficiencies, for example, angular stomatitis for
riboflavin deficiency, and eye lesions or xerophthalmia for Vitamin A deficiency.
However, before such clinical signs become apparent, “subclinical” stages of deficiency
develop as –
 Nutritional deficiency is usually initiated by an inadequate dietary intake of
KSOU, Mysuru. 49
one or more nutrients resulting from either a low content in indigenous food
sources or the presence of exogenous factors that interfere with the
ingestion, absorption, and metabolism of the nutrient. This stage of
nutritional deficiency usually can be identified by the dietary assessment.
 When inadequate intakes persist, the tissue stores become gradually

depleted of that nutrient, resulting in low levels in certain body fluids and
tissues or the activity of nutrient-dependent enzymes. Often, these changes
can be detected by biochemical tests.
 Following the nutrient depletion of body fluids or tissues, functional

changes occur. Functional tests provide a measure of the biological significance
of a given nutrient because they assess the functional consequences of
nutritional deficiency, for example, cognitive function for iron, taste acuity
for zinc, and dark adaptation for Vitamin A.
3.2: BIOCHEMICAL ASSESSMENT
Biochemical assessment is an essential component of nutrition assessment, the first

step in implementing the Nutrition Care Process (NCP) in clinical practice. Laboratory tests
of patients’ blood, urine, feces, and tissue samples are important indicators of nutritional
status and organ function. Because disease states, subsequent treatments, and hydration status
can have a significant impact on biochemical indices, evaluation of laboratory values is
critical in patients with both acute and chronic diseases. While patients with acute illness or
injury may experience dramatic changes in laboratory results, patients with chronic illness
may develop abnormal lab results more slowly.
Comparing patients' laboratory results to reference values and interpreting

discrepancies in the context of the patient's clinical symptoms and medical history allows
clinicians to prevent or diagnose diseases and develop appropriate nutrition interventions.
Laboratory values are necessary to monitor the effectiveness of medical treatment, evaluate
NCP interventions, and adjust the plan of care appropriately. Unlike the other components of
nutrition assessment, biochemical assessment is a carefully controlled process and considers
only objective data used in the NCP. However, no single laboratory test or panel can be used
to make a diagnosis of nutritional status and needs.
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In the development of any deficiency disorders, biochemical changes can be

expected to occur before clinical manifestations. Therefore, biochemical tests which can be
conducted on easily accessible body fluids such as blood and urine can help to diagnose
the disease at the subclinical stage and confirm the clinical diagnosis at the disease stage-
clinical signs and symptoms often being non-specific. An ideal biochemical test should be
sensitive, specific, easy to carry out, non-invasive, preferably inexpensive, and should reveal
information on the extent of tissue unsaturation rather than short-term fluctuations in the diet.
Biochemical tests can also be used for deriving estimates of nutrient requirements. Many
biochemical tests are the most objective measures of nutritional status but not all are
appropriate. Using a series of lab tests is more reliable than a single test.
Biochemical tests for assessment of nutritional status involve-
 Measurement of the nutrient, its metabolite, or some other product in

blood or urine.
 Measurement of the activity of a vitamin-dependent enzyme and its

correlation with the corresponding coenzyme.
 Measurement of an accumulated metabolite whose disposal depends

on an enzyme.
 Measurement of some end functions like blood clotting, work capacity,

a tensile strength of skin, etc.
Factors that can affect the validity of the measurements include the following:
 No single test is d iagnostic. Combining biochemical data, along

with anthropometric parameters and nutritional intake, probably represents the
most effective practical method for assessing the status and effects of re-
feeding.
 Individual variability in measured response to every measured

function or chemical component results in a range of values to be considered
 What is “normal” is affected by age, gender, physiologic state,

and environmental circumstances.
 Some blood concentrations reflect immediate nutrient intake while
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others reflect long-term status; all factors that affect concentration must be
considered.
3.2.1: TYPES OF SPECIMEN COLLECTION
There are several types of specimens used for nutrient and nutrient-related analyses.
Although the ideal specimens reflect the total body content of the nutrient being assessed,
the optimal specimen is not always readily available. The most common specimens utilized
for analysis in medical nutrition therapy include the following blood components:
Whole blood: Contains red blood cells (RBCs), white blood cells (WBCs), and platelets
suspended in plasma; collected with an anticoagulant when the entire content of the blood is
evaluated and none of the elements are removed.
Serum: Fluid remaining in blood after blood has been clotted and centrifuged to remove the
clot and blood cells.
Plasma: A component of blood composed of water, blood proteins, organic electrolytes,

and clotting factors.
Blood cells: Measurement of cellular components, separated from anti-coagulated whole

blood In addition to blood, other specimens can also be used for analysis.
Urine: Contains a concentrate of excreted metabolites from random samples or timed

collection.
Feces: Determines composition of gut flora and presence or absence of adequate nutrient
absorption, from random samples or timed collection.
Hair and nails: Stable, easy to collect, and noninvasive media which determines exposure
to toxic metals and is a helpful indicator of levels of trace elements (zinc, copper,
chromium, and manganese).
Saliva: Noninvasive medium with high turnover used to evaluate functional adrenal stress
and hormone levels
Breath tests: Performed on the air generated from exhalation; a less common and less
invasive tool to assess nutrient metabolism, use, and malabsorption, particularly of sugars
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Figure- 1 Collection of specimens in the laboratory for biochemical assessment
Biochemical tests can be conducted on easily accessible body fluids including blood
and urine, which can help to diagnose the disease at the subclinical stage. These tests are
precise and measure individual nutrient concentrations in the body fluids like serum retinol,
serum iron, etc., or the detection of abnormal amounts of metabolites.
3.2.1: TYPES OF ASSAY
There are two types of laboratory assays are available to measure nutrient levels in
specimens. One is A static assay used to measure the actual level of a nutrient in the
specimen. This type of assay is specific to the nutrient of interest. Unfortunately, the
concentration of the nutrient within the specimen does not always reflect its amount stored
in body pools and tissues. Serum levels may be influenced by the status of their protein
carriers, which may be altered by inflammation. The amount of nutrients found in serum,
plasma, or another fluid or tissue is influenced by recent dietary intake in static assays. To
address this limitation, overnight (8-12 hours) fasting is recommended when collecting
some specimens. Examples of static assays include serum iron and white blood cell
ascorbic acid.
The second one is a functional assay that measures the specific biochemical or
physiological functioning of a nutrient, rather than just the quantity of the nutrient. Usually,
a functional assay is sensitive to a nutrient at its functional site. Functional assays are not
always specific for one nutrient of interest because many physiological and biochemical
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functions rely on several biological factors beyond the specific nutrient. One example of a
functional assay is serum ferritin, which represents the functioning of iron present in the
cellular storage pool.
3.3: BIOCHEMICAL TESTS
Protein Energy Malnutrition:

Dietary protein and calorie deficiency is the main reason for PEM. There are several
Biochemical tests based on reduction in serum protein, and alterations in nitrogenous
constituents for evaluation of the protein's nutritional status. In nutrition surveys as well as
clinical practice serum albumin measurement is the method of choice. While serum albumin
and transferring reflect long-term changes in protein nutritional status, serum retinol-binding
protein, and thyroxine-binding prealbumin show more rapid changes and can be used for
monitoring protein status.
Essential Fatty Acids:
Fat apart from being a concentrated source of energy provides EFA with
important structural and functional roles in the membrane as a part of phospholipids.
With the advancement in technology, gas-liquid chromatography has made it possible to
measure the EFA.
Fat-soluble vitamins:
Vitamin A
Vitamin A status is generally ascertained through the measurement of serum/plasma
Vitamin A levels, even though it does not give a reliable estimate of tissue (liver)
reserves. A new method-relative dose response (RDR) test is claimed to give a better
indication of vitamin A stores.
Vitamin D
The most accepted indicator of vitamin D status is serum levels of vitamin D

metabolite, 25- hydroxy cholecalciferol (25 HCC). The interpreter guidelines are>10
ng/ml (25 nmoles/L), acceptable; 5-10 ng/ml low, medium risk; <5 ng/ml, deficient, high
risk.
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Vitamin K
Vitamin K is required for the carboxylation of certain glutamic acid residues in

protein precursors of coagulation factors including prothrombin. Their levels can be
measured by spectrophotometric, immunochemical, ELISA, and radioimmunoassay
methods. In Vitamin K deficiency, the prothrombin time is delayed. This is a functional
indicator, but less specific than the above-mentioned biochemical tests.
Water soluble vitamins:
Thiamin
Biochemical assessment of thiamin nutrition status has been done by the measurement of
 Urinary Thiamin
 Blood (serum, RBC, WBC) levels of thiamin or its metabolite thiamin
pyrophosphate (TPP).
 Erythrocyte transketolase activity coefficient.
Urinary Thiamin:
Measurement of urinary thiamin can be done by the thin chrome method, HPLC
technique, or microbiological assay. Though 24 hrs collections over two days are more
desirable, for practical reasons in large nutrition surveys random samples of urine or the
early morning voided samples of urine have been used and values expressed per gram
creatinine.
Blood Thiamin:
Thiamin and its metabolite thiamin pyrophosphate (TPP) in the blood are insensitive
indices of thiamin status.
Riboflavin
Urinary riboflavin can be measured by microbiological assay or fluorometric
method. Information on the relationship between riboflavin nutriture and RBC riboflavin is
limited and controversial. The Erythrocyte glutathione reductase (EGR) test is the most
accepted procedure for assessing riboflavin status
Niacin
Despite difficult procedures, measurement of the ratio of two niacin metabolites, N-

methyl 1-2-pyridoxine – 5- carbonyl amide (2-pyridone) and NI-methyl nicotinamide, is the
best biochemical indicator of niacin nutrition status. A ratio of less than 1 indicates
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deficiency. In normal subjects, it ranges from 1 to 4.
Vitamin B6
Vitamin B6 nutriture has been assessed by measurement of
 Plasma pyridoxal phosphate (PLP).
 Urinary Vitamin B6 or pyridoxic acid.
 Activities of erythrocyte transaminases (aspartate aminotransferase and
alanine aminotransferase) and their in-vitro stimulation with PLP and
 Tryptophan load
Folic Acid:
Blood Folate
Serum as well as RBC folate reflects folate status. While serum levels reflect
dietary intake and readily available tissue reserves, RBC folate is a measure of long-term
folate status and therefore, a better index. Microbiological assay with Lactobacillus casei
as the test organism is the most reliable method of measuring tissue folate. Radio assays
(radiometric binding assays) have been described but are expensive. HPLC methods are
still in the experimental stage.
Vitamin B 12
Blood levels
Vitamin B12 status can be assessed by measuring the serum levels of the vitamin
by microbiological or isotope dilution methods. Euglena gracious is the most suitable
organism.
Schilling test: Apart from a dietary deficiency of vitamin B12 (which is

uncommon), vitamin B12 deficiency can also arise from malabsorption due to a lack of
intrinsic factors (Pernicious anemia) or some other causes. Such malabsorption can be
detected by measuring Vitamin B12 absorption with and without intrinsic factors.
Pantothenic acid:
Pantothenic acid levels in blood and urine can be measured by microbiological assay.
Biotin:
The suggested indices of biotin nutriture are:
 Blood or plasma levels of the vitamin
 Urinary excretion of organic acids like lactic, 3-hydroxy isovaleric, methyl
citric, and 3-hydroxy propionic acids
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 The activity of the biotin-dependent enzyme propionyl CoA carboxylase and

its in vitro activation with biotin in lymphocytes. The normal range of blood
biotin is 120-240 mg/dl (4.92-9.84 mmol/L). Microbiological and isotope
dilution techniques are used for the assay.
Ascorbic Acid:
Both plasma and leucocyte ascorbic acid levels indicate vitamin C status.
Colorimetric and HPLC techniques are available for measuring plasma and leucocyte
ascorbic acid.
Minerals and trace elements:
Calcium:
Blood calcium is almost entirely in the serum and under homeostatic control. Hence,
it is not a sensitive indicator of calcium nutriture. Serum-ionized calcium (50% of total
calcium) is physiologically more important. Bone density measurements can directly reflect
calcium status. Radiographic and single or dual photon absorptiometric methods are
available for measuring bone mineral content.
Iron:
A variety of tests have been described for assessing iron's nutritional status. The
earliest stage of deficiency leading to a reduction in iron stores is reflected in bone marrow
iron and serum ferritin levels.
Iodine:
Urinary and plasma inorganic iodine levels reflect dietary iodine. On adequate dietary
intake, urinary excretion is more than 50 µg/g creatinine. Other methods for assessing iodine
status are,
 Radioiodine uptake by the thyroid
 Plasma protein-bound iodine
 Serum-free or total thyroxine
Zinc:
Plasma Zinc is the most commonly used index of Zinc status. Normal range is 84-
104µg/dl. Amongst the functional tests suggested are a measurement of Zinc dependent
enzyme carbonic anhydrase in blood and more recently serum thymulin (thymic hormone)
without and with the addition of Zinc in vitro.
Copper:
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The most commonly used index of copper nutriture is serum copper levels,
measured by atomic absorption spectrophotometry. Other suggested indices are
erythrocyte copper, ceruloplasmin (copper-dependent enzyme) in serum, and
cytochrome oxidase activity in platelets or leucocytes.
Selenium:
Selenium levels in urine, serum, and blood have been used for assessing selenium
status. Biochemical tests are powerful tools not only for assessing nutrition status but
also for deriving estimates of nutrient requirements.
Normal and Deficiency Indices for Assessing Nutritional Status:
Nutrient Normal Deficiency

Vitamin A (Serum Vitamin A) 30µg/dl <20 µg/dl
Vitamin D – Serum 25-hydroxy cholecalciferol >10mg/ml <5 mg/ml
Vitamin E- Serum Vitamin A/Total lipid Ratio >0.8 -
Vitamin K Absent Accumulate
Thiamin – Urinary thiamin 100mg/24hr -
Riboflavin – Erythrocyte glutathione reductase <1.2 >1.4
Niacin – N-Methyl 1-2 pyridone – 5 carbonyl 1-4 <1.0
amide
Vitamin B6 – Urinary excretion <20 mg/g creatinine
Folic acid – Serum folate >6.0mg/ml <3.0mg/ml
RBC folate >160mg/ml <140mg/ml
Vitamin B12 – Serum B12 200-900pg/ml 80pg/ml
Iron Serum Ferritin levels - 12mg/l
Serum Iron Haemoglobin
- <40mg/dl
>13g/dl (Men) -
>12g/dl (Women) -
Iodine – Urinary Excretion >50mg/g creatinine -
Zinc – P. Zinc 84-104 µg/dl -
Copper – S. Copper 75-125 µg/dl -
Ascorbic acid – P. Ascorbic acid level >0.3 mg/dl <0.2mg/dl
Table – 1 Normal values of vitamins and minerals
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3.4: REFERENCE VALUES OF BIOCHEMICAL TESTS
Table -2: Glucose and lipid profile reference values
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Table –3: Urine test reference values
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Figure – 2: Red blood cells counts
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Table – 4: Serum electrolyte reference values
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Advantages of biochemical assessment:
 Useful in detecting early changes in bodymetabolism and nutrition

 Precise, accurate, and reproducible.
 Useful to validate data obtained from dietary methods e.g. comparing
salt intake with 24-hoururinary excretion.
Limitations of biochemical assessment:
 Time consuming and expensive

 Cannot be applied on a large scale
 Reveal only current nutritional status
3.5: CLINICAL ASSESSEMENT
The clinical examination assesses the levels of health of individuals or of population

groups with the food they consume. It is the simplest and most practical method. When two
or more clinical signs characteristic of a deficiency disease are present simultaneously, their
diagnostic significance is greatly enhanced.
Clinical assessment is an essential feature of all nutritional surveys and the simplest
and most practical method. Utilizes several physical signs (specific and non-specific) that are
known to be associated with malnutrition and deficiency of vitamins and other micro-
nutrients. General Clinical examination with special attention to organs like hair, angles of
mouth, gums, nails, skin, eyes, tongue, muscles, bones & thyroid gland. Detection of relevant
signs helps in establishing the nutritional diagnosis.
Standard physical assessment procedures are used in evaluating nutritional status.

Severe malnutrition produces a variety of physical manifestations. The most notable effects
occur on the skin, mucous membranes, and hair. Rashes, bruises, and other lesions of the
skin, changes in the lips, gums, and tongue, and alterations in the appearance of the hair may
all be evidence of nutrient deficiency. These signs of malnutrition are often non-specific.
Therefore, the appearance of suspicious physical signs requires correlation with the patient’s
history and clinical condition, and whenever possible, confirmation through diagnostic tests.
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CLINICAL SIGNS AND SYMPTOMS OF NUTRITIONAL INADEQUACY FOR

DIFFERENT NUTRIENTS
SITE SIGN DEFICIENCY
General Underweight, short stature Calories
Appearance Oedematous decreased activity level Protein
Hair Easily pluggability sparse, depigmented, Protein
dull Protein, biotin
Dry, brittle hair Vitamin C
Corkscrew hairs
Nails Spoon-shaped, Koilonychia Iron
Transverse dispigmentation Protein
Skin Skin face-moon face, diffuse Protein
depigmentation Vitamin A, Zinc
Dry & scaly flaky point EFA, Riboflavin
Nasolabial seborrhea Iron, B12, Folate
Psoriasiform rash Vitamin A, EFA
Pallor Vitamin C
Perifollicular hemorrhage Niacin
Hyperpigmentation
Eyes Night Blindness Vitamin A, Zinc
Photophobia, Xerosis Vitamin A
Conjunctival inflammation Vitamin A, Riboflavin
Regional field defect Vitamin E
Mouth Glossitis Riboflavin, B6, Niacin, B12
Bleeding gum Vitamin B12, Folate, Vitamin
Angular stomatitis C, Riboflavin
Cheilosis Riboflavin, B6, Niacin
Decreased taste and smell Riboflavin, B6, Niacin
Tongue atrophy Zinc
Loss of tooth enamel Riboflavin, B6, Iron
Calcium
Neck Goiter Iodine
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Parotic enlargement Protein

Gums Swollen, bleeding Vitamin C
Reddened gingival Vitamin A
Teeth Caries Fluoride
Stained teeth Iron
Mottled, pitted enamel Fluoride
Hypoplastic enamel Vitamin- A, D
Skeletal Costoctabes beading Vitamin – C, D
Craniotables, frontal bossing, epiphyseal Vitamin –D
enlargement
Bone tenderness
Vitamin – C
Muscles Decreased muscle mass, decreased grip Protein, Calories
strength Thiamin
Tender claves, muscle pain
Subcutaneous Decreased Calories
tissue
Heart High output failure Thiamine
Chest Respirator muscle weakness Protein, phosphorous.
Abdomen Ascites Protein
Hepatomegaly Protein, fat
Extremities Edema Protein
Bone/joint pain Vitamin A, C
Joint swelling Vitamin C
Neurological Ophthalmoplegia Thiamin, Vitamin E
Hyporeflexia Vitamin E
Sensory loss Vitamin E, B12
Peripheral neuropathy Vitamin E, Thiamine,
Dementia Pyridoxine
Acute disorientation Thiamine, B12, Folate, Niacin
Wide-based gait Phosphorous, Niacin
Tetany Thiamin
Diminished reflexes Calcium, Magnesium
Wrist or foot drop Iodine
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Thiamin
Endocrine Hypothyroidism Iodine
and others Glucose intolerance Chromium
Altered taste Zinc
Delayed wound healing Zinc, Vitamin C
Table -5: Common Clinical Symptoms of Various Nutrients
Physical manifestations of nutrient deficiency typically indicate a state of advanced

depletion. In clinical settings, signs of deficiency for specific nutrients occur far less
frequently than evidence of a more general deficit of protein and energy intake. As a result,
the focus of the physical examination often rests less on the identification of specific
nutrient deficiencies than on acquiring a more global impression of current nutritional status
and the impact of nutritional factors on the patient's medical condition. Muscle wasting,
poor skin integrity, and loss of subcutaneous tissue are typical findings associated with long-
standing protein and energy deficits. Obesity, an increasingly common condition, is strong
evidence of nutritional imbalance as well as an increased health risk.
This method is reliable and easy to organize. However, it requires an experienced
investigator to assess the symptoms. Early clinical signs and symptoms of malnutrition are
rather vague and often include weakness, lethargy, irritability, and lightheadedness. Many of
the symptoms are non-specific for single nutrient deficit and may be caused by insufficiency
of one or several nutrients.
The various signs and symptoms of nutrition deficiency disorders have been discussed
below:
NUTRITIONAL DEFICIENCY SIGNS AND SYMPTOMS
DISORDERS
Kwashiorkor  Edema
 Underweight
 Apathy and irritability
 Moon face
 Hair and skin changes
Marasmus  Extreme muscle wasting-“skin and
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bones”
 Loose and hanging skin folds
 Old man’s or monkey face
Marasmic Kwashiorkor  Extreme muscle wasting-“skin and
bones”
 Loose and hanging skin folds
 Old man’s or monkey face
 Edema
 Absolute weakness
Vitamin A Deficiency Changes in the eye –
 Conjunctival xerosis: dryness of the
transparent membrane that covers the
cornea and lines inside of the eyelid.
 Xeropthalmia: cornea becomes soft
and raw and easily infected
 Bitot’s spot is dry foamy, triangular
spots appearing on the temporal side
of the eye
 Night blindness: inability to see in dim
light
Iron Deficiency Anaemia  Paleness of conjunctiva
 Paleness of tongue
 Paleness of mucous of soft plate
 Low hemoglobin
 Swelling of feet in severe anemia
 Spoon shaped nails
Iodine Deficiency Disorder  Thyroid enlargement
 Abortions, congenital abnormalities
 Cretinism
Riboflavin Deficiency  Angular stomatitis- lesions on both
angles of the mouth
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 Glossitis- tongue bright red or

magenta
 Chlorosis- lips become red and
develop cracks
Niacin Deficiency  Dermatosis- Symmetrical skin lesions
evident only on areas exposed to
sunlight
Vitamin C Deficiency  Spongy bleeding gums
Rickets  Changes in the skeletal system – such
as beading of ribs, pigeon chest,
protruding breast bone, knock-knee or
both legs
Essential Fatty acid Deficiency  Lesions in the skin- generally seen on
the back of the elbow, around knees,
and sides.
Fluorosis  Mottled teeth with chalky white and
brownish areas with or without
erosion of enamel
Table -6: Various signs and symptoms of the nutrition deficiency disorders
VITAMIN A DEFICIENCY:
XEROPHTHALMIA BIGOTS SPOT
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CONJECTIVA
NIACIN DEFICIENCY:
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VITAMIN D DEFICIENCY:
OSTEOPOROSIS RICKETS
VITAMIN E DEFICIENCY VITAMIN B12
DEFICIENCY
VITAMIN C DEFICIENCY:
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3.6: FUNCTIONAL TESTS:

Functional Nutrition is a non-invasive way to definitively determine areas of
nutrient deficiencies and imbalances and find the right supplements to overcome these
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body stressors. The following tests are done during a Functional Nutrition assessment:
 Oral pH to determine the acidity or alkalinity of the body.
 Zinc taste test to determine zinc sufficiency.
 Iodine patch test and Basal body temperature test to determine thyroid health.
 Blood pressure is taken from laying down to standing up and Pupillary
light response is to determine adrenal.
 health
 Cuff test to determine mineral sufficiency.
 Pressure on various Chapman and other reflex points to determine
organ and endocrine (hormone).
 Gland health.
 Deep abdominal pressures to determine small intestine and colon health.
Detoxification, or full-body Cleansing, is another arena often used in Functional
Nutrition to significantly reduce your risk of various chronic diseases of lifestyle such as high
cholesterol, high blood pressure, heart disease, stroke, cancers, and Alzheimer’s disease. Elimination
or Anti-inflammatory Diets are often helpful for those of you with joint and muscle aches and pains,
various skin conditions, fibromyalgia, arthritis, and overall body inflammation.
3.7: SUMMARY:
 Biochemical assessment deals with measuring the level of essential dietary

constituents in body fluids – blood and urine, which helps evaluate the possibility
of malnutrition.
 Biochemical changes occur before the onset of clinical changes.
 Clinical examination is one of the common tools used to assess the extent of
clinical forms of undernutrition.
 Clinical signs are changes in the body that are indicative of nutritional
deficiency or excess.
 Clinical indices are useful for identifying the severity of the problem and
measuring progress toward long-range goals to eradicate nutrient
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deficiencies.
 Static and functional laboratory tests are primarily used to detect subclinical
nutrient deficiency states, and to confirm a clinical diagnosis.
 Static biochemical tests measure levels of the nutrients in biological

specimens while functional biochemical tests determine the changes in the
activities of enzymes dependent on a given nutrient.
 The biochemical assessment provides useful information on the level of

nutrients necessary to meet biological demands, the bioavailability and
metabolism of nutrients, and the impact of anintervention.
 Functional tests assess the physiological performance of an individual in vivo such

as immune competence, taste activity, night blindness, muscle function, and work
capacity.
 Growth and development responses such as lactation and sexual function also can
be assessed.
 None of the functional physiological tests are specific and must be interpreted
along with biochemical measurements.
3.8: GLOSSARY:
Inflammation: When something damages your cells, your body releases chemicals that
trigger a response from your immune system.
Lipoproteins: Lipoproteins carry cholesterol and triglycerides to cells in the body.
Malnutrition: lack of proper nutrition, caused by not having enough to eat
Nutrition care process (NCP): It is a systematic method that dietetics and nutrition
professionals use to provide nutrition care.
Assay: Examination and determination as to characteristics (such as weight, measure, or
quality.
RDR: Relative Dose Response.
ELISA: Enzyme-linked Immunosorbent Assay.
TPP: Thiamin Pyrophosphate.
EGR: Erythrocyte Glutathione Reductase.
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PLP: Plasma Pyridoxal Phosphate

Pernicious anemia: it is an autoimmune condition that affects your stomach.
Xerosis: The medical term for dry skin is xerosis. Xerosis refers to abnormally dry skin or
membranes, such as those found in the mouth or the conjunctiva of the eye.
Ascites: It is the abnormal build-up of fluid in the abdomen.
Marasmus: Extreme muscle wasting skin and bones.
1. Define biochemical assessment.

2. Expand NCP.
3. Mention the tests involved in the biochemical assessment of nutritional status.
4. List the types of specimen collection.
5. What are the types of the assay?
6. What are the advantages of biochemical assessment?
7. Define clinical assessment.

8. Define marasmus
9. What is Iron Deficiency Anaemia?
10. Name the cause of rickets.
11. List the thiamine and niacin deficiency.
12. What is a functional test?
3.11: REFERENCES
1. Bamji M. S, Prahlad Rao N, and Vinodinireddy (2003), Textbook of Human Nutrition

(p-p 197201), New Delhi. Oxford & IBH Publishing Co. PVT. LTD
2. Mahan, K. L., Stump E. S. (2012), Food and the Nutrition Care Process. (13thed)
USA: Saundus Elsevier.
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3. Mary, M. Mary K.R. &Scott .A. S. (2008), Clinical Nutrition for surgical
patients.Jones&Barlett Publishers.
4. Michael C Latham, Human Nutrition in the Developing World. Ithaca, New York,
USA.
5. Srilakshmi B (2005) Nutrition Science (pp 3-14), New Delhi. New Age International
(P) Limited.
1. Bamji M.S, PrahladRao N, Reddy V (2004), Textbook of Human Nutrition, II

Edition, Oxford and PBH Publishing Co. Pvt. Ltd, New Delhi.
2. Gibney, M.J., Margetts, B.M., Kearney, J.M., Arab, L (2004), Public Health
Nutrition, Blackwell Publishing Co. UK.
3. Swaminathan, M (2007) Essentials of Food and Nutrition. An Advanced Textbook
Vol. I, the Bangalore Printing and Publishing Co. Ltd, Bangalore,
4. Srilakshmi B (2010), Nutrition Science, New Age International Publication, New
Delhi.
5. Srilakshmi B (2005) Nutrition Science (pp 3-14), New Delhi. New Age International
(P) Limited.
------------***********-------------
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UNIT-4: DIETARY ASSESSMENT – ADVANTAGES AND DISADVANTAGES
4.0: OBJECTIVES
4.1: INTRODUCTION
4.2: METHODS OF DIET SURVEY
4.3: ANALYSIS AND INTERPRETATION
4.4: DISADVANTAGES OR PROBLEMS IN DIET SURVEY
4.5: SUMMARY
4.6: GLOSSARY:
4.8: REFERENCES
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4.0: OBJECTIVES
After completing this chapter, the reader should be able to:

 Study the importance of diet surveys in assessing the nutritional status,
 Understand the different methods of diet surveys.
 List the methods for measuring usual dietary intake.
 Describe the methods for measuring food and nutrient intake.
 Explain the various challenges encountered with diet assessment methods.
 Know the disadvantages and problems of dietary assessments
4.1: INTRODUCTION
Accurate and consistent measurement of dietary intake and patterns of eating

behavior is important when evaluating the effectiveness of public health interventions to
assess the nutritional status and improve diet and also for elucidating the relationship of
nutrient intake with deficiency as well as degenerative diseases like obesity, and
Diabetes Mellitus. etc. Measurement of dietary intake is complex and the most
appropriate measurement method will depend on: the objectives of the surveillance; the type
of data required; available resources and the population of interest. Information on food
consumption patterns is also essential for assessing the food needs of population groups at the
national/regional level. Quantitative information on a diet is also needed for fixing minimum
wages and organizing rationing, and mass/community feeding programs
The measurement of dietary intake is complex and presents significant challenges,

particularly at a group and population level. The appropriate method of measurement will
depend on the objectives of the surveillance and the types of information required. For
example, a policymaker may be interested in dietary intake data to measure the behavioral
response to a campaign to encourage healthy eating or to estimate the differences between
the nutrient intakes of a particular population subgroup. In contrast, a commissioner may
require more detailed information about the nutritional status of a population to determine
how nutrition and dietetics services should be resourced and targeted.
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In the context of public health nutrition, self-report methods are commonly used
to collect food intake data. This is because they usually use fewer resources than
alternative methods, such as the use of biomarkers or clinical indicators. Assessment of
food intake is potentially subject to many sources of both random and systematic error. The
recall ability and psychological characteristics of individuals can influence dietary
reporting. Wherever possible, it is important to identify and quantify sources of potential
errors when assessing food intake, particularly when deriving nutrient intake. In principle,
all tools should be tested for reliability and validity. Reliability refers to the likelihood that an
instrument or tool will measure the same thing each time it is used – either with the same
or a different respondent. Validity refers to how accurately the instrument reflects the
actual behavior. For example, an instrument that was developed to monitor population-level
nutrient intake may not be valid and reliable for evaluating changes in dietary intake for
a smaller group participating in a healthy eating intervention. Self-report tools can be
tested against more reliable and objective methods of assessment such as doubly labeled
water to measure energy intake, or nitrogen or protein intake.
A dietary survey is one of the direct methods of assessment of nutritional status. The
dietary inquiries are of two types, one which concentrates on qualitative aspects of the food
that are what kind of foods are eaten and the other includes the estimate of the amount of
food consumed in terms of quantity. The qualitative type gives information about foods
include, including the type of food consumed, frequency, attitude towards food, cultural
significance, physiological conditions like pregnancy and lactation, etc. In quantitative
analysis, the exact amount consumed in terms of grams/liters is assessed.
Nutrition data and indicators, as well as the capacity of, and support to
all countries, especially developing countries, for data collection and analysis,
need to be improved to contribute to more effective nutrition surveillance, policy-
making, and accountability.
4.2: METHODS OF DIET SURVEY
There are various ways of conducting dietary surveys:

a) Food Frequency Questionnaires (FFQ)
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b) Twenty-four-hour recall
c) Weighed intake
d) Food frequency
e) Food records or diaries
f) Diet History or Short Dietary Assessment Instrument
g) Food Balance Sheet Method
h) Duplicate sampling.
i) Household Consumption and Expenditure Surveys- Household food
consumption
Food Frequency Questionnaire (FFQ):
It is usually used in longitudinal studies to assess food habits. It elicits information

about the frequency of consumption and portion size of food. FFQ includes two sections: one
section contains a food checklist, while the other could allow the subjects' comments.
Respondents indicate their frequency per day, per week, or month. Typically, FFQ is used in
epidemiologic studies on dietary lifestyles and chronic diseases, but it may also be used in
clinical settings. It is easy and cheap to administer, and generally, it is positively evaluated by
respondents. The main disadvantage of FFQ-style tools is that they ask respondents to provide
'typical' frequencies and portion sizes, generally, over the previous year and require mental
averaging over varying intakes and seasons. These strategies might introduce cognitive biases
in dietary evaluation.
Healthy Eating Index (HEI):
Developed in 1995 and revised in 2005, the Healthy Eating Index is one of the many
dietary indexes published. In general, a dietary index aims to measure the quality of nutrition
even though it is not aimed at assessing the diet in terms of energy, micronutrient, and
macronutrients. A dietary index is particularly useful for evaluating the diet of a population,
but it could also be used as a supportive tool in clinical settings, where clinicians,
psychologists, or researchers are interested in collecting standardized data about food patterns.
Food Records or Diaries
Diaries contain categories and quantities of foods consumed per day. Subjects record
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the foods and beverages, and their quantities consumed over one or more days. It involves the
maintenance of dietary records of weighed quantities of foods consumed by an individual/
family according to the number of days of the survey. Overall energy intake is recorded with
pictures, scales, or other measures. An advantage of this assessment method is that diaries
provide quantitative information about food consumed during the recording time, and a large
sample can be covered in a short time through mailed questionnaires provided the population
is educated.
There are two main problems inherent to this assessment strategy. First, if you need to
gather collective data, for example, for research purposes, you have to consider potential data
distortions due to a sampling bias, since subjects' involvement results in an elevated
motivation, rendering data not representative of the broad population. Second, you cannot be
sure if the diary is compiled on a day-by-day basis. When the recording time increases (more
than 7 days), the validity of the recalling decreases.
24-Hour Dietary Recalls
A particular tool to collect data about nutritional behavior is 24-hour dietary recalls.
Interviews are conducted to gather data. The principal aim of this tool is to record in detail
food and beverage intake in the previous 24 hours. In this method, a set of "standardized
cups" suited to local conditions are used. Subjects are asked to complete a 24-hour recall for
the previous day. The subject has to report eating occasions, time, mood (alone or in a group,
at home, at a restaurant, etc.), and frequency of consumption. The tool requires an exhaustive
description of preparation and portion measure.
A disadvantage of this tool concerns cognitive and motivational biases. For

instance, many subjects might find it difficult to distinguish between what they remember
eating and what they ate a few hours ago. Furthermore, implicit motives could lead the
subject to report only, some part of their meal, maybe omitting to report less-healthy foods
or what they consider that a physician would evaluate as a bad choice. The subjects may
not communicate their food intake correctly for different factors connected to memory,
understanding and knowledge, interview condition, and so on. This tool was often used to
evaluate the percentage of the population that adopts satisfactory or unsatisfactory diets.
Two benefits of this tool are:
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 Literacy of the subjects is not required in advance, because an expert interviewer will
administer the instrument. As a result of this, the 24-hour dietary recall is useful
across a wide range of populations.
 A dietary recall occurs after the food has been consumed, so the dietary
assessment will have a minor impact on dietary choice (reactivity). Alternatively,
other methods, such as FFQ, generally have a more relevant impact on dietary
choice.
Diet History or Short Dietary Assessment Instrument
The diet history approach was proposed by Burke and Stuart in 1940. This method
is useful for obtaining qualitative details of diet and studying patterns of food consumption
at the household or industrial level. It is used to evaluate a specific range of food intake
instead of the total diet. It assesses, for example, the intake of fruit and vegetable, grains,
dairy products, the percentage of energy from fat, and so on. It is useful in clinical settings and
health promotion programs. Diet History or Short dietary assessment instruments are
usually used to help individuals change their diet. The procedure includes an assessment
of the frequency of consumption of different foods-daily, weekly or fortnightly, or
occasionally and the number of times included, meal patterns, dietary habits, likes and
dislikes, taboos and beliefs, culture, physiological conditions, etc. In contrast to other
assessment instruments, short instruments focus on specific eating behaviors. However,
they fail to detect information on the whole diet of an individual.
The use of these brief methods may be advantageous for characterizing, the
population's average intake, discriminating between individuals or populations, analyzing
relations among food habits and other variables (e.g. sex, age, race, and diet), and
comparing data collected in different trials for research purposes or population
surveillance. Short methods are particularly useful in contexts where it is not necessary to
analyze in detail the quantitative aspects of a diet. Hence, these methods investigating only
a specific component of a diet may play an important role in dietary monitoring in clinical
settings, health promotion, and education.
Food Balance sheet method (FBS)
This method is useful when information regarding the availability of food is needed at
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the macro level. The food and Agricultural Organization (FAO) was the first to compile FBS
for different countries at the global level in the year 1949. FBS is computed based on the food
supplies for the known period either at the regional or national level. This includes food used
for animal feeds, exports, seeds, and wastages
Hence, FBS is used by administrators and planners for monitoring the food availability
in the country and to take steps during crises.
Inventory (food list) method
This method is useful and employed in institutions like hostels, orphanages/old age
homes, arm barracks, etc. the amount of foodstuff issued to the warden and entered in records
is considered. This method can be used even at the household level, provided the respondents
maintain a regular record of the foods used. The investigator has to make two or three visits
one at the beginning of the survey when the checklist of food stocks is given to the
housewives and one at the end of the week to collect the data.
This method will give only the estimated food consumption rather than the actual food
consumed by each individual in a family and this method can be used for fairly educated
families and those that subsist on a cash economy where food is usually purchased from the
market.
Weighing (raw and cooked food) method
In this method, food is measured using an accurate balance. Raw foodstuffs as well as
cooked foods should be weighed. It is ideal to collect information for 7 consecutive days
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avoiding the feasting and fasting days. Foods are converted to nutrients by referring to Food
Composition Table and nutrient intake is computed per Consumption Unit (CU).
Expenditure pattern method
In this method money spent on food as well as non-food items are assessed by
administering a specially designed questionnaire. It is assessed for the previous month or
week.
Duplicate sample (chemical analysis)
In this method, the individual is required to save on a separate plate a duplicate sample
of each food eaten by the individual for a whole day. These samples are collected and
analyzed chemically for accurate nutrient consumption.
Household Consumption and Expenditure Surveys - Household Food Consumption
Household food consumption has been defined as "the total amount of food available
for consumption in the household, generally excluding food eaten away from the home unless
taken from home". There is a wide range of multipurpose household surveys, such as the
Household Budget Survey (HBS), the Living Costs and Food Survey (LCFS), the Household
Income and Expenditure Survey (HIES), the Living Standards Measurement Study (LSMS),
the Household Expenditure Survey (HES) and the Integrated Household Survey (IHS) – that
measure food consumption or its proxies, are collectively known as HCESs. The central
statistical offices in countries are usually responsible for data collection. Household members
keep records of all expenses and types of foods consumed during a specific period, usually
one to four weeks, and preferably evenly distributed during different times in the year, which
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is then provided to enumerators. The collected data are analyzed and used to assess food
consumption at the household level. Surveys of this type are routinely undertaken in many
countries to provide information for the calculation of consumer price indices, study
household living conditions, and analyze trends in poverty and income distribution. In some
low-resource settings, the information generated from these surveys is the only form of food
consumption data that can also be used to calculate estimates of nutrient intake. These
estimates are calculated by multiplying the average food consumption data by the
corresponding nutrient values for the edible portion of the food. Data on nutrient values are
obtained from food composition tables. However, household surveys do not provide
information on the distribution of food consumption between family members, cooking
methods, or food losses. These surveys are often performed for economic reasons rather than
for nutrition or health reasons.
4.3: ANALYSIS AND INTERPRETATION
The data collected using various methods according to the requirement is tabulated
and analyzed as - descriptive and analytical procedures. The descriptive analysis provides
information regarding the demographic profile, facilities, sociocultural factors, etc which
influence the dietary patterns of the population. The analytical procedure includes
quantification variables.
4.4: DISADVANTAGES OR PROBLEMS IN DIET SURVEY
Some of the problems faced by the invigilators are - the area of the survey,
distance, lack of rapport with the respondent or the community, duration, and timings of the
survey. Even the best diet survey gives only an approximate estimate of foods and
nutrients consumed. However, information regarding the amount of absorption and utilization
cannot be computed. A combination of diet surveys and clinical and biochemical assessments
with anthropometric assessments will give the exact nutritional status of the individuals or
communities.
The 24-hour recall method has some advantages. First, the 24-hour recall is relatively
quick and convenient. It is typically inexpensive and places little burden on the subject, who
is more willing to respond. Refusals to answer requests for data in this format are less likely.
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One of the main strengths of the 24-hour recall is that it facilitates comparisons among
population groups while describing their unique dietary intakes.
Several limitations have been identified using the 24-hour recall method. These
methods are not specific to the clinical setting. An individual’s diet intake may vary from day
to day, and a 24-hour period may not represent daily variation, which is why collecting data
on two non-consecutive recalls is a best practice when using the 24-hour recall to estimate the
usual daily dietary intake. To manage limitations, multiple 24-hour recalls on non-consecutive
days be conducted before applying the results to the individual’s regular eating habits.
There are several advantages of food records. For one, they do not rely on an
individual’s memory, because the data are recorded at the time of consumption. Using a food
record or diary also has several limitations, regardless of the care setting. First, the timing of
collecting and recording dietary intakes may be atypical for a participant's regular food intake.
FFQ method can be self-administered, takes little time to complete (30–60 minutes),
and places minimal burdens on study participants.44 Administrating this tool to large
population groups is inexpensive and can assess current or past diet. The short versions can
focus on precise nutrients with few food sources. Data received from this method are
representative of usual intake and capture habitual food intake. The advantages listed make
the FFQ the preferred method for evaluating diet-disease relationships in epidemiologic
studies. FFQ have no negligible limitations and are not unique to one particular care setting.
The facts generated are subjective because of reliance on participant memory recall.
4.5: SUMMARY
 A diet survey provides information about dietary intake patterns of specified foods
consumed and estimated nutrient intakes.
 It indicates relative dietary inadequacies, which help plan health education
activities and changes needed in the agriculture and food production industries.
 A combination of diet surveys and clinical and biochemical assessments with
anthropometric assessments will give the exact nutritional status of the individuals or
communities.
 Nutrition data and indicators, as well as the capacity of, and support to all countries,
especially developing countries, for data collection and analysis, need to be improved
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to contribute to more effective nutrition surveillance, policy-making, and

accountability.
4.6: GLOSSARY:
Food and Agricultural Organization: It is a United Nations is an international

organization that leads international efforts to defeat hunger and improve
nutrition and food security.
Inventory: A complete list of items such as property, goods in stock, or the contents of
a building.
Consumption Unit: To convert household income to equivalent income (per unit of
consumption) the concept of "consumption unit" is applied internationally,
taking into account the economies of scale that occur according to the number
and the ages of the people who share the home spends.
1. Define dietary survey.
2. List the types of dietary assessment.

3. Write the befits of 24-hour dietary recalls
4. What are the advantages of a diet survey?
5. What are the problems faced in diet surveys?
4.8: REFERENCES
1. Antia. P, Clinical Nutrition and Diet Therapy, Oxford publication.

2. Srilakshmi. B, (2005): Dietetics, V Edition, New Age International (P) Ltd,
Publishers, Chennai.
3. Dr. Swaminathan.M, Food and Nutrition, 2nd Edition 1985, Reprint 2006. The
Bangalore Printing and Publishing
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4. Garrow J.S James W. P.T. and Ralph A (2000) Human Nutrition and Dietetics, 10th
edition, Churchill Livingston, London.
1. B Srilakshmi (2019), Textbook of Dietetics - Multi Colour 8th Edition, New Age
International (P) Ltd., Publishers, New Delhi-110 002, India.
2. Bamji M.S. and Vinodini Reddy (1998) Text Book of Human Nutrition, Ford and
IBH Publishing Co. Ltd New Delhi.
3. Thompson, FE, and Byers, T. Dietary assessment resource manual. J Nutr.
1994;124(11 Suppl): 2245S-2317S.
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BLOCK-II: NUTRITIONAL PROBLEMS
Malnutrition refers to both undernutrition and overweight, and can be considered as

an imbalance in energy, protein and/or other nutrient intake. Undernutrition can take the form
of stunting, a reduction in linear growth of children, and wasting, having lower than normal
weight for height. A diet deficient in vitamins or minerals can also cause micronutrient
malnutrition, or ‘hidden hunger’. Both undernutrition and overweight have an impact on
population health and are a strain on health-care systems. Nutritional deficiencies occur for a
variety of reasons, such as, an inadequate supply or variety of foods in the diet or because
disease processes interfere with the absorption and metabolism of nutrients. Vitamin A
deficiency is a public health problem in India although an extreme form of vitamin A
deficiency has become rare.
The body needs a variety of nutrients to stay healthy which is obtained from a
balanced diet. Minerals are needed in balanced proportions. Minerals interactions in foods,
digestive tract and within the body play a significant role in the way they are absorbed and
function in the body. Mineral interactions are an important criterion in determining their
physiological need for a person. The condition encompasses both undernutrition and
overweight and obesity. Food intake and feeding behaviours in children are determined by
the way a family eats and their socio-economic backgrounds. Nutritional adequacies are a
reflection of access to adequate quantities of nutritious foods like fresh fruits and vegetables,
legumes, nuts, meat and milk. Lack of knowledge, about appropriate foods and feeding
practices for the child’s age and inadequate awareness and or means for proper caring and
health-seeking behaviours are other causative factors.
LEARNING OUTCOME:
 Describe the symptoms of deficiency of vitamins and effects of excess of vitamin intakes.
 Describe the effects deficiency and excess of energy and macronutrient intakes.
 Describe the symptoms of deficiency of minerals.
 Understand the national programs to combat the major nutritional problems.
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UNIT-5: MACRO NUTRIENT DEFICIENCY AND EXCESS – CARBOHYDRATES,

PROTEINS AND FATS
STRUCTURE
5.1. OBJECTIVES
5.2. INTRODUCTION
5.3. PROBLEMS OF DEFICIENT AND EXCESS OF ENERGY INTAKE
5.3.1. DEFICIENCY OF ENERGY OR NEGATIVE ENERGY BALANCE
5.3.2. EXCESS OF ENERGY INTAKE OR POSITIVE ENERGY BALANCE
5.3.3. OVERWEIGHT OBESITY
5.4. PROBLEMS OF DEFICIENT AND EXCESS INTAKE OF CARBOHYDRATE
5.4.1. CARBOHYDRATE DEFICIENCY
5.4.2. EXCESS CARBOHYDRATE INTAKE
5.4.3. DIETARY FIBRE
5.4.4. DIETARY CARBOHYDRATE AND DISEASE
5.5. PROBLEMS OF DEFICIENT AND EXCESS INTAKE OF PROTEIN
5.5.1. DEFICIENCY OF PROTEIN
5.5.2. FACTORS RESPONSIBLE FOR PROTEIN ENERGY MALNUTRITION
5.5.3. FORMS AND CLINICAL FEATURES OF PEM
5.5.3.1. KWASHIORKOR
5.5.3.2. MARASMUS
5.5.3.3. MARASMIC KWASHIORKOR
5.5.3.4. CLASSIFICATION OF PEM
5.5.3.5. COMPLICATIONS OF PEM
5.5.3.6. TREATMENT OF PEM
5.5.3.7. EXCESS OF PROTEIN INTAKE
5.6. PROBLEMS OF DEFICIENT AND EXCESS OF FAT INTAKE
5.6.1. EFFECTS OF INADEQUATE FAT INTAKE
5.6.2. ADVERSE EFFECTS OF OVERCONSUMPTION OF FAT
5.7. SUMMARY
5.8. GLOSSARY
5.9. FURTHER SUGGESTED READING
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5.1. OBJECTIVES
After studying this unit, you will be able to
 Describe the effects deficiency and excess of energy intakes
 Describe the effects deficiency and excess of macronutrient intakes
5.2. INTRODUCTION
Malnutrition refers to both undernutrition and overweight, and can be considered as an
imbalance in energy, protein and/or other nutrient intake. Undernutrition can take the form of
stunting, a reduction in linear growth of children, and wasting, having lower than normal
weight for height. A diet deficient in vitamins or minerals can also cause micronutrient
malnutrition, or ‘hidden hunger’. Both undernutrition and overweight have an impact on
population health and are a strain on health-care systems. Most countries are affected by a
combination of nutrition challenges, sometimes referred to as the double burden of
undernutrition and obesity or sometimes as the multiple burden of malnutrition.
Almost no country in the world is exempt from some form of malnutrition, and diet-related
health conditions are still dominating the rank of the global health risk. Other nutrition-
related risk factors in the top 20 included high body mass index (BMI), high fasting blood
glucose, high total cholesterol and dietary risk factors (diet low in fruits, vegetables, whole
grains, nuts and n-3 fatty acids, and high in sodium). It is estimated that 90% of deaths from
NCDs, under the age of 70 years old, could be prevented through lifestyle changes to reduce
risk factors.
The historical focus of public health nutrition has been on undernutrition, which is still a
major problem across all levels of development. In economically developed countries
undernutrition is a common feature of ageing, though nutrition-related chronic
noncommunicable diseases such as obesity, type 2 diabetes, cardiovascular disease and
several common cancers predominate. Increasingly, as less economically developed countries
undergo nutritional transition, they are experiencing a rising burden of these diseases, so that
these are now the major nutrition-related disease burden globally. The Indian nutritional
scenario can be gauged by the following table, which shows the key nutrition and dietary
indicators of Indians.
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Table 1: Key nutrition and dietary indicators of Indians
Indicators NFHS-5 NFHS-4

(2019-21) (2015-16)
Child Feeding Practices and Nutritional Status of Urban Rural Urban Rural
Children
Children under age 3 years breastfed within one hour of 44.7 40.7 41.8 41.6
birth (%)
Children under age 6 months exclusively breastfed (%) 59.6 65.1 63.7 5 4.9
Children age 6-8 months receiving solid or semi-solid 52.0 43.9 45.9 42.7
food and breastmilk (%)
Breastfeeding children age 6-23 months receiving an 11.8 10.8 11.1 8.7
adequate diet (%)
Non-breastfeeding children age 6-23 months receiving an 14.2 12.0 12.7 14.3
adequate diet (%)
Total children age 6-23 months receiving an adequate diet 12.3 11.0 11.3 9.6
(%)
Children under 5 years who are stunted (height-for-age) 30.1 37.3 35.5 38.4
(%)
Children under 5 years who are wasted (weight-for- 18.5 19.5 19.3 21.0
height) (%)
Children under 5 years who are severely wasted (weight- 7.6 7.7 7.7 7.5
for-height) (%)
Children under 5 years who are underweight (weight-for- 27.3 33.8 32.1 35.8
age) (%)
Children under 5 years who are overweight (weight-for- 4.2 3.2 3.4 2.1
height) (%)
Nutritional Status of Adults (age 15-49 years)
Women whose Body Mass Index (BMI) is below normal 13.2 21.2 18.7 22.9
(BMI <18.5 kg/m2) (%)
Men whose Body Mass Index (BMI) is below normal 13.0 17.8 16.2 20.2
(BMI <18.5 kg/m2) (%)
Women who are overweight or obese (BMI ≥25.0 kg/m2) 33.2 19.7 24.0 20.6
(%)
Men who are overweight or obese (BMI ≥25.0 kg/m2) 29.8 19.3 22.9 18.9
(%)
Women who have high risk waist-to-hip ratio (≥0.85) (%) 59.9 55.2 56.7 -
Men who have high risk waist-to-hip ratio (≥0.90) (%) 50.1 46.4 47.7 -
5.3. PROBLEMS OF DEFICIENT AND EXCESS OF ENERGY INTAKE

Macronutrient intakes of individuals are reflected in their energy balance. Energy balance is
the difference between energy intake and total energy expenditure. A state of balance is said
to occur when its energy expenditure is equal to its energy intake. If energy intake and
expenditure are not equal, the result will be either a positive energy balance, in which body
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energy stores (and mainly fat) are increased, or a negative energy balance, in which the body
falls back on using its energy stores (fat, protein and glycogen). Consequently, the body’s
energy balance (along with other factors) determines to a large extent its weight and general
health status.
5.3.1. Deficiency of energy or negative energy balance

Deficiency of energy or negative energy balance seldom occurs independently more often
than not, it occurs along with protein and macronutrient deficiency because of inadequate
food intake. Protein energy malnutrition is the commonest type of malnutrition in developing
countries.
5.3.2. Excess of energy intake or positive energy balance

Excess of energy intake or positive energy balance has become the bane of modern lifestyle.
The frequency of obesity has increased dramatically in many developed and developing
countries. This is of public health importance due to negative effect of obesity, especially
when centrally distributed, to non-communicable diseases of lifestyle. Although genetics,
environment and lack of exercise may be factors in, whether an individual who is at risk will
become overweight or obese. Excess energy in any form will promote body fat accumulation
and excess consumption of low-fat foods, while not as obesity-producing as excess
consumption of high fat products, will lead to obesity if energy expenditure is not increased.
5.3.3. Overweight obesity

Terms ‘overweight’ and ‘obese’ are different and can be determined by determining body
weight, body mass index (BMI) and body fat mass. An adult who has a BMI of 23–24.9
kg/m2 is said to be overweight, while an adult with a BMI in excess of 25 kg/m2 is said to be
obese. In the case of children and adolescents, the various BMI and weight ranges are
different from those of adults, and the fact that normal levels of fat in the body vary
depending on gender and age must be taken into account.
Causes of obesity: There are different causes for the development of obesity, which are
related to genetics, human biology, hormones and environmental factors. These are discussed
here:
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Overconsumption of calories and obesity: An imbalance between energy intake and energy
expenditure is considered the most important factor. When we consume more calories than
we expend for our daily needs (basal metabolic rate, thermogenic processes and activity), this
extra energy is stored in the body, mainly as fat stored in fat tissue, in order to be used later as
an energy fuel. Therefore, apart from the quality of the diet and the proportion of fat, protein
and carbohydrates, the total quantity of energy intake and energy consumed is most important
for the energy balance of the body.
Role of dietary fat intake in the development of obesity: The increase in fat intake of the
modern diet and reduced physical activity are the two main causes for the development of
obesity in industrialised countries.
Role of sugar and carbohydrate intake in the development of obesity: This relationship
depends on the total amount consumed and energy requirements, as well as the type of
carbohydrate and how refined or complex it is. For example, a high consumption of simple
carbohydrates (in the form of non-starch polysaccharides) produces an imbalance on the
blood glucose levels, a greater feeling of hunger and lower satiety and caloric over-
consumption. On the other hand, a diet that is high in complex carbohydrates from fruits,
vegetables, legumes and whole wheat and grain products provides a large amount of dietary
fibre, which may play an important role in producing greater satiety and weight loss, while
the parallel lowering of total-fat intake in the diet can also result in a spontaneous reduction
in total energy (caloric) intake and weight loss in overweight and obese persons.
Genetics: Interaction between relevant environmental and genetic factors play a role in the
development of obesity.
Consequences of obesity: People who have overweight or obesity, compared to those with
healthy weight, are at increased risk for many serious diseases and health conditions. There is
an increase in- the mortality rate from all causes of death. Obesity increases risk of high
blood pressure hypertension), High LDL cholesterol, low HDL cholesterol, or high levels of
triglycerides (dyslipidaemia), many types of cancers. There is an increased risk of Type 2
diabetes; risk of coronary heart disease, stroke, gallbladder disease. Osteoarthritis (a
breakdown of cartilage and bone within a joint) is associated with obesity and overweight.
Sleep apnoea and breathing problems are more common and in general quality of life is low.
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Mental illness such as clinical depression, anxiety, and other mental disorders is also seen due
to reduced social interaction as obesity increases body pain and difficulty with physical
functioning.
Prevention and treatment of obesity: Choosing healthier foods (whole grains, fruits and
vegetables, healthy fats and protein sources) and beverages. Limiting unhealthy foods
(refined grains and sweets, potatoes, meat, processed foods) and beverages (sugary drinks)
Increasing physical activity are the hallmark of prevention and treatment. Following the
dietary guidelines given by ICMR and other apex health organisations is helpful.
5.4. PROBLEMS OF DEFICIENT AND EXCESS INTAKE OF CARBOHYDRATE

The primary role of carbohydrates (sugars and starches) is to provide energy to cells in the
body, particularly the brain, which is the only carbohydrate-dependent organ in the body.
Cereals are our staple food. They are a rich source of carbohydrates. In the Indian dietary,
about 65 to 80 per cent energy is provided by carbohydrates. They are often classified as
digestible or glycaemic and indigestible or non-glycaemic carbohydrates, the latter being the
dietary fiber.
5.4.1. Carbohydrate deficiency

Carbohydrate deficiency technically does not occur as body can maintain its blood glucose
levels within normal limits by generating glucose from other building blocks such as lipids
(glycerol) and amino acids. This is exemplified by the normal glucose levels in populations
(e.g., Innuits and Eskimos) that consume diets with zero carbohydrate intake. This does not
suggest that low carbohydrate intakes are beneficial.
In most populations a minimum of 50g/ day is required to prevent ketosis. In addition to
providing easily available energy for oxidative metabolism, carbohydrate-containing foods
are vehicles for important micronutrients and phytochemicals and is not associated with
adverse health effects. Diets high in carbohydrate as compared to those high in fat, reduce the
likelihood of developing obesity and its co-morbid conditions. An optimum diet should
consist of at least 55% of total energy coming from carbohydrate obtained from a variety of
food sources. On the other hand, adverse effects are seen when carbohydrate consumption
levels are at or above 75% of total energy intake as high carbohydrate intake will be at the
cost of other essential macro nutrients.
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Dietary carbohydrate provides maximum calories in Indian diets and more than half is
contributed by refined grains in urban adults and 75% in rural adults. The percent energy
from carbohydrate is in the range of >60-78% in urban and rural areas. Therefore,
considering cultural aspects, changed scenario of physical activity levels as well as cost
considerations, the recommended dietary intakes (RDA 2020) is- 55-60En% from
carbohydrates with proteins contributing 10-15 En% and fats contributing 20-30 En%.
5.4.2. Excess carbohydrate intake

In developing countries, weaning children frequently consume very high carbohydrate
intakes from a single or a small number of sources. In developed countries, children have
higher intakes of carbohydrate from more sources than adults. In both situations, at least 55%
of carbohydrate energy from a variety of sources is the optimum.
It has been observed that where variety in the food supply is low and carbohydrate intake is
high, a low birth weight is more common.
An exception can be made in case of the elite endurance-trained athlete. A high carbohydrate
diet during a few days preceding an endurance event, carbohydrate loading, a high
carbohydrate pre-event meal and carbohydrate supplementation in the form of carbohydrate-
containing beverages have all been shown to enhance performance during long-distance
cycling and running.
5.4.3. Dietary fibre

Recommendations for fibre is based on energy intake and the level of about 40 g/2000 kcal
has been considered as safe intake (RDA 2020). Insufficient consumption of dietary fibre
contributes to a plethora of chronic disorders such as constipation, diverticulitis,
haemorrhoids, appendicitis, varicose veins, diabetes, obesity, cardiovascular disease, cancer
of the large bowel and various other cancers. Emerging research has also begun to investigate
the role of dietary fibre in immunomodulation. Too much dietary fibre has health
consequences. Dietary fibre has been shown to inhibit absorption of micronutrients like
minerals and some vitamins. Insoluble fibre binds the divalent elements minerals non-
specifically and reduces their absorption.
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5.4.4. Dietary carbohydrate and disease

Carbohydrates may directly influence human diseases by affecting physiological and
metabolic processes, thereby reducing risk factors for the disease or the disease process itself.
Carbohydrates may also have indirect effects on diseases, for example, by displacing other
nutrients or facilitating increased intakes of a wide range of other substances frequently found
in carbohydrate-containing foods.
Obesity: There is no evidence to suggest that the macronutrient composition of a low energy
diet influences the rate and extent of weight loss in the treatment of obese patients. It may be
noted that high carbohydrate foods promote satiety in the short term. Diets high in non-
glycaemic carbohydrates are bulky and promote lower energy intakes.
Non-insulin dependent diabetes mellitus (NIDDM): High rates of NIDDM in all population
groups are associated with rapid cultural changes in populations previously consuming
traditional diets, and also with increasing obesity, especially when centrally distributed.
Certain populations including South Asians appear to have a strong predisposition to the
development of NIDDM to the extent that in some groups about half the adult population
have the disease. Genetic predisposition, diet and lifestyle-related conditions which may lead
to obesity will clearly influence the risk of developing NIDDM in populations.
Foods rich in non-starch polysaccharides and carbohydrate-containing foods with a low
glycemic index appear to protect against diabetes, the effect being independent of body mass
index. Consuming a wide range of carbohydrate foods is now regarded as acceptable in the
nutritional management of people who have already developed NIDDM. It has been
suggested that between 60 and 70 per cent of total energy should be derived from a mix of
mono-unsaturated fatty acids and carbohydrates.
Cardiovascular disease: Obesity, particularly when centrally distributed, is associated with
an appreciable increase in the risk of coronary heart disease. There is also evidence
implicating specific nutrients and, in particular, high intakes of some saturated fatty acids
appear to be important promoters of coronary heart disease. On the other hand, there is
increasing evidence of a strong protective effect by a range of antioxidant nutrients.
Increasing carbohydrate intake can assist in the reduction of saturated fat and many fruits and
vegetables rich in carbohydrates are also rich in several antioxidants. Intake of cereal foods
rich in non-starch polysaccharides, at the expense of fat, are protective against coronary heart
disease. Increase in carbohydrates resulting from increased consumption of vegetables, fruits
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and appropriately processed cereals, over prolonged periods help in maintaining healthy lipid
profiles.
Cancer: Diet is widely regarded as important in the etiology of colorectal cancer with meat
and fat considered the primary risk factors, and fruit, vegetable and cereal foods considered to
be protective. Dietary carbohydrate is thought to be protective through mechanisms involving
arrest of cell growth, differentiation and selection of damaged cells for cell death (apoptosis).
This is probably achieved primarily through the action of butyric acid which is formed in the
colon from fermentation of carbohydrates such as resistant starch and non-starch
polysaccharides. Such carbohydrates are found mostly in cereals, fruit and vegetables.
Carbohydrate staple foods are a source of phytoestrogens which may be protective for breast
cancer.
Gastrointestinal diseases: Intakes of non-starch polysaccharides and resistant starch are the
most important contributors to stool weight. Therefore, increasing consumption of foods rich
in these carbohydrates is a very effective means of preventing and treating constipation, as
well as haemorrhoids and anal fissures. Bran and other cereal sources containing non-starch
polysaccharide also appear to protect against diverticular disease and have an important role
in the treatment of this condition.
Dental caries: The incidence of dental caries is influenced by a number of factors. Foods
containing sugars or starch may be easily broken down by α-amylase and bacteria in the
mouth and can produce acid which increases the risk of caries.
5.5. PROBLEMS OF DEFICIENT AND EXCESS INTAKE OF PROTEIN

Proteins are the most complex macronutrients and the chemical building blocks composing
our body. The quality of proteins depends on the essential amino acids they consist of, as well
as their digestibility, their absorptive capacity and their biological value.
5.5.1. Deficiency of protein

Malnutrition is a general term for a medical condition caused by an improper or insufficient
diet. The term usually refers to generally bad or faulty nutrition and is most often related to
undernutrition. According to the World Health Organization (WHO), malnutrition is the
‘cellular imbalance between supply of nutrients and energy and the body’s demand for them
to ensure growth, maintenance and specific functions’, and is the greatest risk factor for
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illness and death worldwide. Protein energy malnutrition (PEM) refers to “an imbalance
between the supply of protein and energy and the body's demand for them to ensure optimal
growth and function”. PEM is a spectrum of conditions ranging from growth failure to overt
marasmus or kwashiorkor. PEM are classified into three forms- Kwashiorkor, Marasmus and
Marasmic. kwashiorkor. Due to the rapid growth and development and their physiological
vulnerability PEM is mostly seen in children below 5 years.
5.5.2. Factors responsible for protein energy malnutrition

Anorexia and loss of appetite: Anorexia can result from several factors related to
physiological, psychological and general social problems.
Inadequate food intake or lack of food supplies: are probably the most common causes of
malnutrition worldwide, especially in developing, but also in developed, countries. The main
cause of PEM is food inadequacy. PEM was earlier attributed to the concept of ‘protein gap’
(deficiency of proteins in diet). ‘Food gap’ is the chief cause of PEM. It is not only the
deficiency of proteins but inappropriate food (low in energy density, protein and
micronutrients‐ Vitamin A, Iron, Zinc), poor both quantitatively and qualitatively.
Dietary quality: In Indian diets almost 60 % of protein is obtained from cereals which have
relatively low digestibility and quality. Data of disadvantaged populations from slums, tribals
and sedentary rural Indian populations show that the protein intake (mainly from cereals) is
about 1 gm/kg/day as revealed from the NNMB surveys. Individuals at risk of a deficient
protein intake is high in rural and tribal adult populations.
Low BMI: There is a high prevalence of low BMI, compounding the burden in disadvantaged
populations.
Infection: Food deficiency and insufficiency are responsible for PEM characterised by
wasting and stunting. PEM also supresses primary as well as secondary response to infection.
Also the body’s ability to consume, digest and utilize nutrients is compromised. PEM
becomes life threatening when susceptibility to infectious diseases (that would not normally
be lethal), increases especially when they are cyclic.
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Malnutrition infection vicious cycle
Maternal malnutrition: Malnutrition in-utero results in low birth weight. Maternal

malnutrition can further worsen the situation due to failure to meet the nutritional needs of
the new-born.
Child feeding practices: Such as diluted milk formula and diets with bulky foods result in
low nutrient density. Young children need frequent feeding with nutrient dense foods due to
their small stomach volumes.
Environmental factors: Unsanitary living conditions result in increased incidence of disease.
Incidence of PEM increases during natural and man-made calamities.
Free radicals: Environmental pollution and contaminated foods particularly Aflatoxins result
in increasing the body’s demands for radical scavengers thereby increasing demands for
protein and natural antioxidants. This imposes a greater strain on liver function and can result
in protein deficiency. It has also been suggested that oxidative stress seen in Kwashiorkor
may be the effect of protein deficiency rather than its cause; some amino acids notably
cysteine are needed for the body’s internal antioxidant mechanism.
5.5.3. Forms and clinical features of PEM

Three forms of PEM are kwashiorkor, marasmus and marasmic kwashiorkor. These are
described briefly in following paragraphs.
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5.5.3.1. Kwashiorkor
The main cause of this form of malnutrition is inadequate protein intake and the low
concentration of essential amino acids. Kwashiorkor (from the West African word for
‘displaced child’) is a severe form of undernutrition, which develops in individuals on diets
with a low protein/energy ratio with tapering of breastfeeding and reliance on starchy foods.
The main symptoms of Kwashiorkor: are oedema, wasting, liver enlargement,
hypoalbuminemia, steatosis and the possible depigmentation of skin and hair. The symptoms
are:
Growth failure: Underweight and stunting, are important feature of Kwashiorkor. This can be
assessed by knowing the body weight.
Muscle wasting is severe but it may be masked by presence of oedema. This is one of the
main causes of underweight.
Oedema: Pitting oedema occurs first on lower limbs and progresses to other parts of the
body. The classic feature moon face occurs due to puffy face and swollen eyelids. Due to
low plasma albumin levels (20g/l.). Presence of oedema can mask the extent of actual weight
loss.
Low potassium levels are due to decrease in the number of cells, cellular organelle and also
loss of functional capacity to pump sodium out and potassium in by energy-dependent
sodium potassium ATPase mechanism. As a result, there is increased sodium and water
retention in the cells and also a compensatory rise in sodium pumps. Potassium levels are
much lower in Kwashiorkor compared to marasmus and are also one of the reasons of apathy
in these children
Enlarged liver occurs due to fatty infiltration.
Mental changes: Apathy and irritability are common features.
Skin changes: Scaly pigmentation of skin is common. In severe cases a feature known as
crazy pavement dermatosis is seen. This is characterised by peeling and depigmentation of
skin.
Hair changes: Changes in hair colour and texture occur. Hair is easily pluckable. In some
cases, ‘flag sign” that is, alternate bands of depigmented and pigmented hair occur. Hair
changes are linked with deficiency of important amino acids such as cysteine and are
reversed during nutrition rehabilitation.
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Anorexia and Diarrhoea: are common and limits food intake and utilization. Anorexia is
common making it difficult to feed the child. Diarrhoea may be present due to defective
digestion or absorption or secondary infection.
Secondary micronutrient deficiencies: leading to xerophthalmia, glossitis, angular stomatitis
may be seen. Plasma retinol binding protein is lowered and results in vitamin A deficiency.
Deficiencies of the micronutrients and trace elements in Kwashiorkor are linked with low
levels of albumin and other proteins that are transporters of many of the fat-soluble vitamins
such as vitamins A and E and trace elements.
Haematological changes: are present. Moderate anaemia due to reduced haemoglobin
synthesis occurs due to protein deficiency. Hypersegmented neutrophils are seen. Neutrophil
leucocyte response to infection is often impaired.
Hormonal and other changes: are responsible for dysadaptation. Increase in hormones
somatomedin C, growth hormone, plasma free fatty acids and decreased levels of free amino
acids (muscle proteins are not mobilised) and lipo-protein is there.
5.5.3.2. Marasmus
Word marasmus is derived from the Greek word for ‘to waste away’) is the other form of
protein energy malnutrition, which is caused by the inadequate intake of both protein and
energy. In Indian cereal-based diet, the dietary intakes of children are inadequate in calories
but not in protein, and the rates of marasmus are twice as high as that of Kwashiorkor.
Main symptoms of marasmus: Main symptoms are:

Cachexia a form of severe weight loss as a result of wasting in infancy and childhood. Severe
wasting, with little or no oedema, minimal subcutaneous fat, severe muscle wasting. Child
looks appallingly shrivelled, thin, wrinkled skin and displays bony prominences.
Skin and hair changes are infrequent.
Micro nutrient deficiency: Associated micronutrient deficiencies are seen.
Adaptation: Better metabolic adaptation compared to Kwashiorkor is seen in case of
marasmus. Albumin levels are lowered (25 g/l.), but not as much as seen in kwashiorkor.
Hepatic and pancreatic functions are better maintained in marasmus. Oedema and fatty
infiltration prominent signs in kwashiorkor are absent in marasmus.
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Diarrhoea: due to defective digestion while common in kwashiorkor is not that common in
marasmus.
Cortisol levels: Increased cortisol levels is seen resulting in muscle protein mobilisation
enabling near normal amino acid levels.
Serum lipoproteins: are better maintained and liver triglycerides are mobilised preventing
fatty liver.
5.5.3.3. Marasmic kwashiorkor

It is common in areas where PEM is highly prevalent. Children exhibit features of marasmus
as well as kwashiorkor. Transition between two forms is also seen characterised by – a)
Hypometabolism (↓ energy expenditure, ↓ physical activity, ↓ protein turnover) b) Endocrine
changes (↓ serum T3, ↓ insulin, ↑↓ catecholamines, ↓ IGF-1) c) Altered cardiovascular and
renal function (↓ cardiac output, ↓ heart rate, ↓ blood pressure, ↓ renal plasma fl ow, ↓
glomerular fi ltration) and d) Changes in Immune system (lymphocyte depletion, ↓
complement components, alterations in monokines or cytokines.
5.5.3.4. Classification of PEM

Indices based on body weight and height: These indices help to know the prevalence,
magnitude and duration of malnutrition. Weight for age index is useful to assess the
magnitude of the problem in community, but does not indicate duration or type of
malnutrition. Weight for height is an index that gives a measure of nutritional status
independent of age. Height for age is an index which gives an estimate of prevalence of
stunting in the community and indicates duration of malnutrition.
Underweight being underweight for one’s age Weight for age
Stunted being too short for one’s age Height for age
Wasted being dangerously thin Weight for height
Classifications: There are different ways to classify malnutrition. Purpose of classification is

to know the severity and type of PEM in order to rationalize treatment and community action.
Classification of malnutrition is based on loss of body weight based on a percentage of usual
weight and in some cases presence or absence of oedema. PEM is also classified as
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oedematous or non-oedematous PEM. Choice of classification depends on the purpose for

which it is used.
a. Gomez classification is based on weight for age. In this system the normal reference child is
the 50th centile of the Boston standard. It must be noted that Boston standard used in above
classification is no longer an international reference. Weight for age (%) = (Weight of the
child / Weight of the normal child of same age ) X100.
Stage of Malnutrition Weight for age (%)

Normal > 90 %
Grade I 75 – 90 %
Grade II 60 – 75 %
Grade III < 60
Gomez classification is easy to use because weight is very easy to measure. There are several
disadvantages, such as: a cut of point of 90 % is high (80 % is equivalent to – 2SD or 3rd
percentile) so some normal children are classified as grade I malnutrition.  Only weight is
measured so it is difficult to know that if the low weight is due to an acute malnutrition or
long-standing chronic malnutrition.
b. IAP classification is also based on weight for age.
Stage of Malnutrition Weight for age (%)
Normal > 80 %
Grade I 70 – 80 % Mild
Grade II 60 – 70 % Moderate
Grade III 50 ‐ 60 % Severe
Grade IV < 50
c. WHO classification: This is based on NCHS reference standard. Median used here is the
Median weight of NCHS reference population.
Weight below Median minus 2SD ( M ‐ 2SD) Moderate malnutrition
Weight below Median minus 3SD ( M – 3 Severe Malnutrition
SD)
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d. Waterlow's classification: This classification takes into account both weight and height
measurements along with age. This is a consistent system based on three indices (weight for
hight, hight for age and weight for age.
W/H > m# – 2 SD* < m – 2 SD
H/A
> m – 2SD Normal Wasted
< m – 2SD Stunted Wasted and Stunted
# NCHS mean * Z scores
Drop in Height for age (< 90%) Stunted
Drop in Weight for Height (<80%) Wasting
Drop in Weight for Age (<80%) Under weight
Use of standard deviation unit (Z scores) has been suggested. The cut off level if minus 2
standard deviation units of NCHS standard.
e. Wellcome’s classification of severe malnutrition in children is a system for classifying
protein–energy malnutrition in children based on percentage of expected weight-for-age and
the presence or absence of oedema.
Weight Oedema
Reference standard (50th Presence or absence
percentile)
Underweight 80 ‐60 % without oedema
Kwashiorkor 80 ‐60% with oedema
Marasmus ‐Kwashiorkor < 60 % with oedema
Marasmus < 60 % without oedema
5.5.3.5. Complications of PEM

Most hospitalizations of PEM children are due to infection, diarrhoea and dehydration. PEM
results in short term as well as long term complications such as- water, electrolyte and
mineral imbalance, hypothermia, hypoglycaemia, secondary infections, vitamin deficiency,
lactose intolerance, cardiac failure, bleeding tendency, renal impairment. Long term effects of
PEM are growth retardation and mental retardation. Severe acute malnutrition (SAM),
defined as severe wasting [weight-for-height Z score <−3 based on World Health
Organization (WHO) reference standard] and/or the presence of nutritional oedema, is a life-
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threatening condition which needs urgent attention and appropriate management to reduce
mortality and promote recovery.
5.5.3.6. Treatment of PEM

The treatment of a malnourished patient is determined by their general health, levels of
weight loss and food intake and should follow the guidelines for the treatment of adult
patients at risk of developing refeeding syndrome, a fatal medical condition that may affect
malnourished and/or ill patients who receive an inappropriately high protein/calorie intake.
Dehydration: Due to diarrhoea this is very common. Patients with mild or moderate
dehydration can be treated by oral or nasogastric administration of fluids. Oral rehydration
solution contains sodium chloride (3.5 g), potassium chloride (1.5 g) sodium bicarbonate (2.9
g) and glucose monohydrate (22 g), made up to 1 L with potable water (sucrose, 40 g, may
replace glucose).
Oral rehydration salts (ORS) solution for severely malnourished children Because severely
malnourished children are deficient in potassium and have abnormally high levels of sodium,
the oral rehydration salts (ORS) solution should contain less sodium and more potassium than
the standard WHO-recommended solution. Composition of oral rehydration salts solution for
severely malnourished children (ReSoMal) suggested by WHO is given below:
Component Concentration (mmol/l)
Glucose 125
Sodium 45
Potassium 40
Chloride 70
Citrate 7
Magnesium 3
Zinc 0.3
Copper 0.045
Osmolarity 300
Mode of feeding: When normal food intake provides insufficient levels of energy and protein,
additional nutrition can be given to the patient enterally or parenterally, when the
gastrointestinal tract does not function properly meet their nutritional needs.
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Protein supplementation: Milk-based diets, rich in high-quality protein, are the first choice of
treatment of Kwashiorkor. Studies at the NIN have also confirmed the effectiveness of milk-
based and mixed protein-based diets. Vegetable protein in the treatment of Kwashiorkor
make these diets affordable to the poor after discharge from the hospital as well as for
community-level prevention of Kwashiorkor. Mixed protein diets may not be as effective in,
reducing oedema and increasing serum albumin levels in children with oedematous
malnutrition, but equally effective in terms of cure rates compared to milk protein alone.
Potassium: plays a key role in the resolution of oedema. It is assumed that the deficiency is
less likely to be due to dietary inadequacy, but may be due to gastrointestinal losses as
malnourished children are relatively inefficient in retaining the potassium. Potassium intakes
through diet or ORS or ReSoMal must be ensured.
Treatment for catch-up growth: After the initial stabilization phase when the metabolic
machinery gets back to normalcy and oedema subsides, high-energy dense foods are
recommended for rapid catch-up growth and the management is similar for oedematous and
non-oedematous malnutrition. The most important limiting factor for promoting weight gain
with the only milk-based diets is energy. It is important to increase the energy density of
diets. Calorie intakes of 160-220 kcal/kg/ day and protein intakes of 2-4 g/kg/day have been
recommended during nutrition rehabilitation phase by the WHO. Studies carried out at the
NIN have also shown that the mixed protein diets providing about 200 kcal/kg/day energy
and 4-6 g/kg/day of protein associated with the highest rate of weight gain.
Community-based management of severe acute malnutrition: An important problem with
facility-based nutrition rehabilitation is the high default rates, mainly because families find it
difficult to stay away from their homes for longer periods due to economic and other
constraints. In community or home-based management of children with uncomplicated SAM,
an estimated 85 per cent of the total cases can lead to recovery rates similar to that of facility-
based management and are better accepted by the community at large. Improvement in
protein quality of supplements provided in the nutrition programmes, by taking due care of
the PE ratio adjusted for PDCAAS (>90 of WHO/FAO reference protein) is therefore needed.
Ready-to-use therapeutic foods (RUTF) vs. Local foods in a community-based nutrition
rehabilitation programme: Rates of weight gain of children receiving RUTF and those
receiving local foods are comparable. Using local foods may be more sustainable.
Uncomplicated SAM is an extension of moderate wasting and may be treated as a continuum
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of the same disease. Compared to RUTF, locally available nutrient-dense foods offer
advantages of lower cost, wider acceptability and availability; the existing programmes in the
country such as Integrated Child Development Services, therefore, need to be strengthened
for effective delivery of nutrient-dense local foods to the children with uncomplicated SAM.
5.5.3.7. Excess of protein intake

In addition to recommending adequate protein consumption, the ICMR also suggests that
protein intake not exceed 30- 40% of energy intake in adults. Diets containing an excessive or
disproportionate amount of protein do not provide additional health benefits. Instead, high
protein intakes may increase health and disease risks. One area of concern is the effect of
excess protein on the kidneys. Kidneys are responsible for excreting excess nitrogen as urea.
Thus, high-protein diets may overburden the kidney’s capacity to excrete nitrogen wastes.
When excess protein is primarily from a high intake of animal proteins, the overall diet is
likely to be low in plant-based foods and consequently low in fiber, some vitamins (vitamins
C and E and folate), minerals (magnesium and potassium), and beneficial phytochemicals.
Another concern, particularly with athletes, is the health risks associated with excess protein
and amino acid supplementation. As described earlier, our bodies are designed to obtain
amino acids from dietary sources of whole proteins. This assures a supply of amino acids in
proportions needed for body functions and prevents amino acid toxicity, especially for
methionine, cysteine, and histidine—the most toxic amino acids (when consumed in excess).
When individual amino acid supplements are taken, chemically similar amino acids can
compete for absorption, resulting in amino acid imbalances and toxicity risk.
5.6. PROBLEMS OF DEFICIENT AND EXCESS OF FAT INTAKE

Lipids form a broad category comprising fats, oils, waxes and various other compounds like
lipoproteins, phospholipids and cholesterol. They are all water-insoluble and very useful for
living organisms. Fats are food components insoluble in water that represent a condensed
source of energy. From a chemical aspect, they are fatty acids, and from a nutritional aspect,
they include fatty acids and other lipids, such as phospholipids, sterols, such as cholesterol,
and synthetic lipids. According to epidemiological and clinical studies, trans fatty acids and
to a lesser extent saturated fatty acids (mainly from animal products such as meat and dairy)
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of the diet are positively associated with coronary heart disease, hypertension and insulin
resistance.
The percentage of energy consumed as fat can vary widely, and the diet can still meet energy
and nutrient needs. Dietary guidelines from the World Health Organization and the Dietary
Reference Intakes recommend a total fat intake between 20 and 35% of total calories. The
minimum of 20% is to ensure adequate consumption of total energy, essential fatty acids, and
fat-soluble vitamins and prevent atherogenic dyslipidaemia (low high-density lipoprotein
cholesterol (HDL-C), high triglyceride-rich lipoproteins) which occurs with low-fat, high
carbohydrate diets and increases risk of coronary heart disease.
5.6.1. Effects of inadequate fat intake

Total fat: If intakes of fat, along with carbohydrate and protein, are inadequate to meet
energy needs, the individual will be in negative energy balance. Depending on the severity
and duration, this may lead to malnutrition or starvation. In an energy-sufficient diet,
carbohydrate can replace fat as a source of energy. In some populations, fat intakes are very
low and body weight and health are maintained by high intakes of carbohydrate; resulting in
an Increased risk of chronic diseases such as coronary heart disease (CHD) and diabetes.
Chronic nonspecific diarrhoea in children has been suggested as a potential adverse effect of
low-fat diets. It is considered a disorder of intestinal motility that may improve with an
increase in dietary fat intake in order to slow gastric emptying and alter intestinal motility.
n-6 and n-3 Polyunsaturated Fatty Acids: Cis-polyunsaturated fatty acids (PUFA) include
essential fatty acids and have beneficial roles in human health. However, formal clinical
deficiency of n-6 and n-3 fatty acids is rare in healthy individuals. Deficiency is rare because
adipose tissue lipids in free-living, healthy adults contain about 10 percent of total fatty acids
as linoleic acid, biochemical and clinical signs of essential fatty acid deficiency do not appear
during dietary fat restriction or malabsorption when they are accompanied by an energy
deficit. However, long term deficient intakes can exhibit signs of deficiency. This situation is
rare.
5.6.2. Adverse effects of overconsumption of fat

Total fat: The increase in fat intake of the modern diet and reduced physical activity are the
two main causes of the development of obesity in industrialised countries. Fat is the most
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energy-dense nutrient in our diet, producing nine calories per gram, which is more than twice
the calories derived from other macronutrients such as carbohydrates and proteins. At the
same time, dietary fat is more efficiently metabolised and stored in body fat than
carbohydrates are. Finally, although very fatty foods provide a high amount of calories, in
parallel with an intense feeling of enjoyment and pleasure, they do not produce a strong
feeling of satiety. For this reason, they are usually overconsumed, which encourages the
passive over-consumption of calories and the development of obesity by affecting the body’s
total energy balance. Over-consumption and the extra amount of dietary fat intake can lead to
its storage in fat tissue (in percentage terms sometimes as high as 96%).
One of the main mechanisms through which dietary fat can contribute to the development of
obesity is the regulation of leptin levels. Experiments have shown that an increased dietary
fat intake results in central leptin resistance, whereas the restriction of dietary fat can lead to a
partial improvement in leptin signalling, resulting in a spontaneous reduction in appetite and
body weight.
Saturated fats: Higher intake of saturated fats results in elevated LDL cholesterol
concentration and risk of CHD. Epidemiological studies suggest for each 1 percent increase
in energy from saturated fatty acids, serum LDL cholesterol concentration increases by 0.033
mmol/L. The relative risk of CHD mortality was 1.4 with a corresponding increase of 1
mmol/L of total serum cholesterol concentration. A number of epidemiological studies have
reported an association between saturated fatty acid intake and risk of CHD. The majority of
these studies have reported a positive relationship between saturated fatty acid intake and risk
of CHD and CHD mortality.
Trans Fatty Acids: There is no safe level of consumption (zero tolerance) of
industrial trans fats from partially hydrogenated oils. Trans fats adversely affect a diverse
range of CVD risk factors; they raise LDL-C, raise triglycerides, lower HDL-C, increase
inflammation, promote endothelial dysfunction, and may promote hepatic fat synthesis,
resulting in far greater risk of developing CHD than any other macronutrient. Based on these
effects, the recommendation is to limit their intake as much as possible.
CHECK YOUR PROGRESS

Answer the following
1. What is the dual burden of malnutrition?
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2. What is energy balance?

3. Explain the effect of deficient intake of dietary fiber.
4. Define malnutrition and PEM.
5. Why are children with marasmus said to be better adapted than those with
kwashiorkor?
6. Why is ORS important in treatment of PEM?
7. Why are local foods and home-based management of children with PEM
8. What is the effect of excess protein intake?
9. What are problems associated with deficient fat intake?
10. List the different classifications of PEM.
Fill in the blanks

1. Extent of current status of stunting in children under five years is ___________ and
____________ per cent in rural and urban population.
2. An adult who has a BMI of ________ kg/m2 is said to be overweight, while an adult
with a BMI in excess of __________ kg/m2 is said to be obese.
3. In most populations a minimum of ___________g/ day is required to prevent ketosis
4. RDA for energy from carbohydrate, proteins and fats is ___________En%,
_____________ En% and ______________ En%.
5. Three types of PEM are _______________, ____________________and
_________________.
6. Safe level of trans fat intake is _________g/day.
5.7. SUMMARY
India is in developmental transition and is facing the dual burden of malnutrition. The
pretransition diseases like undernutrition and infectious diseases as well as post-transition,
lifestyle related degenerative diseases such as obesity, diabetes, hypertension, cardiovascular
diseases and cancers are wide-spread in India. The last National Family Health Survey
(NFHS) – 5 indicates a slight decline in undernutrition, but a slight increase in burden of
overnutrition. Macronutrients such as carbohydrate, proteins and fat contribute to the energy
intakes. Food gap results in overall deficiency of macronutrients and results in undernutrition
(PEM). Conversely, overnutrition results from an over intake of macronutrients. The
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recommended dietary intakes (RDA 2020) is- 55-60En% from carbohydrates with proteins
contributing 10-15 En% and fats contributing 20-30 En%. Imbalance in the intake of this
recommendation can cause deficiencies in any one of the macronutrient disorders e.g.,
Kwashiorkor is caused due to protein deficiency. At the community level prevalence of PEM
can be found out by assessment of height and weight indices. By taking suitable measures
disorders of under and overnutrition can be prevented and treated.
5.8. GLOSSARY
NCD Noncommunicable diseases (NCDs), also known as chronic diseases
tend to be of long duration and are the result of a combination of
genetic, physiological, environmental and behavioural factors.,
NFHS The National Family Health Survey (NFHS) is a large-scale, multi-
round survey conducted in a representative sample of households
throughout India. Five rounds of the survey have been concluded.
BMI Body mass index (BMI). An index of fatness and obesity. The weight
(in kg) divided by the square of height (in m).
Satiety The quality or state of being fed or gratified to or beyond capacity.
Anorexia Lack of appetite.
Oedema A condition characterized by an excess of watery fluid collecting in the
cavities or tissues of the body.
Glycemic and non- The glycemic response to a food or meal is the effect that food or meal
glycemic has on blood sugar (glucose) levels after consumption. Glycemic
carbohydrates carbohydrates are broken down by digestive enzymes for blood glucose
and insulin levels to rise after eating them. Those carbohydrates
(dietary fiber) not digested by the body’s enzymes are non glycemic
carbohydrates.
En% % of the energy intake
NCHS The National Center for Health Statistics (NCHS) is a U.S. government
agency that provides statistical information to guide actions and
policies to improve the public health of the American people.
Z score A Z-score is a numerical measurement used in statistics of a value's
relationship to the mean (average) of a group of values, measured in
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terms of standard deviations from the mean. If a Z-score is 0, it

indicates that the data point's score is identical to the mean score. A z-
score of +2 indicates that the data point falls two standard deviations
above the mean, while a -2 signifies it is two standard deviations below
the mean. A z-score of zero equals the mean.

1. Bamji, M.S., Krishnaswamy, K and GMV Brahmam, 2017, Textbook of human
nutrition, 4th ed., Oxford and IBH, New Delhi.
2. WHO, 1999, Management of severe malnutrition: a manual for physicians and other
senior health workers, Geneva.
ANSWER TO CHECK YOUR PROGRESS

1. Malnutrition refers to both undernutrition and overweight, and can be considered as
an imbalance in energy, protein and/or other nutrient intake. Undernutrition can take
the form of stunting, a reduction in linear growth of children, and wasting, having
lower than normal weight for height. A diet deficient in vitamins or minerals can also
cause micronutrient malnutrition, or ‘hidden hunger’.
2. Energy balance is the difference between energy intake and total energy expenditure.
A state of balance is said to occur when its energy expenditure is equal to its energy
intake. If energy intake and expenditure are not equal, the result will be either a
positive energy balance, in which body energy stores (and mainly fat) are increased,
or a negative energy balance, in which the body falls back on using its energy stores
(fat, protein and glycogen).
3. Insufficient consumption of dietary fibre contributes to a plethora of chronic disorders
such as constipation, diverticulitis, haemorrhoids, appendicitis, varicose veins,
diabetes, obesity, cardiovascular disease, cancer of the large bowel and various other
cancers and probably fibre in immunomodulation.
4. According to the World Health Organization (WHO), malnutrition is the ‘cellular
imbalance between supply of nutrients and energy and the body’s demand for them to
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ensure growth, maintenance and specific functions’, and is the greatest risk factor for
illness and death worldwide.
Protein energy malnutrition (PEM) refers to “an imbalance between the supply of protein and
energy and the body's demand for them to ensure optimal growth and function”.
5. Better metabolic adaptation compared to Kwashiorkor is seen in case of marasmus.
Albumin levels are lowered (25 g/l.), but not as much as seen in kwashiorkor.
Hepatic and pancreatic functions are better maintained in marasmus. Oedema and
fatty infiltration prominent signs in kwashiorkor are absent in marasmus. Diarrhoea
due to defective digestion while common in kwashiorkor is not that common in
marasmus. Increased cortisol levels are seen resulting in muscle protein mobilisation
enabling near normal amino acid levels. Serum lipoproteins are better maintained and
liver triglycerides are mobilised preventing fatty liver.
6. Because due to diarrhoea dehydration is very common. ORS solutions can be
lifesaving in many instances.
7. Local foods and home-based management of children with PEM is recommended due
to following reasons:
 Rates of weight gain of children receiving RUTF and those receiving local
foods are comparable. Using local foods may be more sustainable.
 Facility-based nutrition rehabilitation is the high default rates.
 In community or home-based management of children with uncomplicated
SAM, an estimated 85 per cent of the total cases can lead to recovery rates
similar to that of facility-based management and are better accepted by the
community at large.
8. High-protein diets may overburden the kidney’s capacity to excrete nitrogen wastes.
When excess protein is primarily from a high intake of animal proteins, the overall
diet is likely to be low in plant-based foods and consequently low in fiber, some
vitamins (vitamins C and E and folate), minerals (magnesium and potassium), and
beneficial phytochemicals.
9. In some populations, fat intakes are very low and body weight and health are
maintained by high intakes of carbohydrate; resulting in an Increased risk of chronic
diseases such as coronary heart disease (CHD) and diabetes. Chronic nonspecific
diarrhoea in children has been suggested as a potential adverse effect of low-fat diets.
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10. List the different classifications of PEM.

a. Gomez classification
b. IAP classification
c. WHO classification
d. Waterlow’s classification
e. Wellcome’s classification
Fill in the blanks

1. Extent of current status of stunting in children under five years is 30.1 and 37.3 per
cent in rural and urban population.
2. An adult who has a BMI of 23–24.9 kg/m2 is said to be overweight, while an adult
with a BMI in excess of 25 kg/m2 is said to be obese.
3. In most populations a minimum of 50g/ day is required to prevent ketosis
4. RDA for energy from carbohydrate, proteins and fats is 55-60En%, 10-15 En% and
20-30 En%.
5. Three types of PEM are kwashiorkor, marasmus and marasmic kwashiorkor.
6. Safe level of trans fat intake is zero g/day.
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UNIT-6: VITAMINS DEFICIENCY AND TOXICITY
STRUCTURE
6.1. OBJECTIVES
6.2. INTRODUCTION
6.3. VITAMIN A
6.4. VITAMIN D
6.5. FOLIC ACID
6.6. VITAMIN B12
6.7. THIAMINE
6.8. NIACIN
6.9. VITAMIN B6 (PYRIDOXINE)
6.10. RIBOFLAVIN
6.11. TOXICITY OF OTHER VITAMINS
6.12. SUMMARY
6.13. GLOSSARY
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6.1. OBJECTIVES
 Describe the symptoms of deficiency of vitamins
 Understand ways to prevent and treat deficiency disorders
 Describe the effects of excess of vitamin intakes
6.2. INTRODUCTION
Nutritional deficiencies occur for a variety of reasons, such as, an inadequate supply or
variety of foods in the diet or because disease processes interfere with the absorption and
metabolism of nutrients. Vitamin A deficiency is a public health problem in India although
extreme forms of vitamin A deficiency has become rare. NNMB surveys show that milder
grades of deficiency like night blindness and bitot’s spots and low serum vitamin A levels,
are common. Deficiencies of other micronutrients like some B-complex vitamins like
riboflavin, folic acid and vitamin B12 are also common. Rickets has become rare, but recent
studies from India show that vitamin D deficiency as judged by serum levels of 25-hydroxy
vitamin D exists in adults. It is suggested that along with the low intake of calcium, this may
be responsible for the high prevalence of osteoporosis. For every frank case of nutrition
deficiency, there are many others who suffer from sub-clinical malnutrition. With regard to
vitamin deficiency diseases only those of vitamin A, vitamin D, thiamine, riboflavin, niacin,
folate and vitamin B12 result in widespread public health problems. Deficiencies of the
remaining vitamins are rare.
Nowadays it is also important to know about the potential adverse effects resulting from the
overconsumption of some vitamins, especially of retinol, vitamin D and vitamin B6. Of late
the risk of overconsumption of vitamins in India has increased as several foods are now being
fortified with nutrients. The Tolerable Upper Limit (TUL) of intake for nutrients has been
therefore defined by the ICMR for Indians. The recommendation for micronutrient
requirements is for healthy populations with no inherent metabolic or physiologic problems.
Nutrient needs may be higher in people with malabsorption problems. There are many drugs
that influence nutrient need. Micronutrients, especially the vitamins, can themselves be drugs
when taken to excess. Nutrient intakes above TUL on a regular basis from non-dietary
supplements can result in toxicity. The following table shows the TUL for vitamins.
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TOLERABLE UPPER LIMIT (TUL) FOR VITAMINS FOR MEN AND WOMEN– (ICMR
2020)
Niacin Vit. Folate Vit. C Vit. A Vit. D
B6
(mg/d) (mg/ (µg/d) (mg/d) (µg/d) (IU/d)
d)
Men 35 100 1000 2000 3000 4000.
Women - - 1000 2000 3000 4000
The TUL is the maximum level of habitual intake from all sources of a nutrient or related
substance judged to be unlikely to lead to adverse health effects in humans
*Note: TUL values are only for non-dietary pharmacological doses
6.3. VITAMIN A
Vitamin A deficiency (VAD)
Vitamin A deficiency can be defined clinically or sub clinically. Xerophthalmia is the clinical
spectrum of ocular manifestations of vitamin A deficiency; these range from the milder
stages of night blindness and Bitot spots to the potentially blinding stages of corneal xerosis,
ulceration and necrosis (keratomalacia). Serum retinol is used for the assessment of
subclinical vitamin A deficiency in a population (not in an individual). Blood concentrations
of retinol in plasma or serum are used to assess subclinical vitamin A deficiency. A plasma or
serum retinol concentration <0.70 μmol/L indicates subclinical vitamin A deficiency in
children and adults, and a concentration of <0.35 µmol/L indicates severe vitamin A
deficiency.
Vitamin A deficiency results from a dietary intake of vitamin A that is inadequate to satisfy
physiological needs. It may be exacerbated by high rates of infection, especially diarrhoea
and measles. It is common in developing countries, but rarely seen in developed countries.
Vitamin A deficiency is a public health problem in more than half of all countries, especially
those in Africa and South-East Asia. The most severe effects of this deficiency are seen in
young children and pregnant women in low-income countries.
There is a dramatic reduction in severe forms of VAD in the country due to - (i) better access
to health care for mothers and children. (ii) Food availability has improved; with policies in
place to make subsidised food grains available and accessible to poor households, there has
been a significant improvement in the overall dietary intake of young children. (iii) Better
infrastructure; roads, communication facilities, electricity supply, water supply and social
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security. All these factors have indirectly contributed to better health care and lower
prevalence of vitamin A deficiency in children.
Aetiology of VAD
VAD is predominantly seen among children between 1 and 5 years. Low-income group
children in tribal and rural areas are more susceptible. Prevalence of VAD is seen more in
drought prone areas. Regional differences exist with prevalence more in East and Southern
parts of the country. The national prevalence of VAD in school-age children and adolescents
in India was around 20%. Following are the aetiological factors in VAD:
Poor diets: inadequate dietary intake of vitamin A and its precursors is the main cause of
VAD in community. Several factors are responsible for this.
Low purchasing power: Many of the vitamin A rich foods (animal foods) are expensive.
Poverty reduces the capacity to procure these foods.
Ignorance: Illiteracy and ignorance prevents mothers from introducing vitamin A rich foods
particularly rich sources of beta carotene such as green and yellow-orange fruits and
vegetables which may be affordable especially when they are in season.
Availability: of some of the carotene rich foods may be affected by season.
Infection: Vitamin-A deficiency and infections aggravate each other, as the deficiency
predisposes the host to infection, which in turn decreases the intestinal absorption of the
vitamin. Infection can even precipitate the symptoms of deficiency in an individual with
marginal levels of the vitamin.
Protein Energy Malnutrition (PEM): Up to half the children with severe PEM have
xerophthalmia. This may be due to reduced synthesis of vitamin A blood transporter (RBP) in
these children.
Clinical signs of vitamin A deficiency

An important physiological function of vitamin A is cell differentiation which is responsible
for maintaining the integrity of epithelial cells. By exerting control on genes, vitamin A, is
important in embryogenesis. This vitamin functionalizes sulphate transfer and incorporation
and therefore, is essential in the synthesis of mucopolysaccharides (tears production; mucous
membranes; skin; ground substance of bones, cartilage, teeth). It is protective in cell mediated
immunity especially in measles and maintains lymphocyte pool, T- cell response and
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Immunoglobulin production. Vitamin A has a role in growth by having a role in bone

remodeling (osteoclasts, maturation and regeneration of epiphyseal cartridge). Vitamin A is
also associated with hemopoiesis. Thus, major functions of vitamin A are related to vision,
reproduction, growth and immunity. Therefore, the deficiency affects these functions
resulting in the following effects.
– Changes in the eye
– Changes to other epithelial tissues of respiratory tract, gastro intestinal tract.
– Morbidity and mortality- Death rate in children with XIB and mild xerophthalmia is
four times higher.
– Vitamin A and measles: fatality rates in communities with XF is 12% higher.
– Nutritional anemia
The earliest sign of VAD disorder is a decreased plasma concentration of retinol (< 20 µg/dl).
This then results in abnormal cell division, which can affect cell-mediated immunity and the
epithelial tissues of the respiratory and digestive tract, making them more susceptible to
infection. This subclinical phase of deficiency is then superseded by observable clinical
changes in the deficiency disorder that is generally referred to as xerophthalmia.
Early stage of VAD disorder (reversible with intervention)
Night Blindness (XN): The first sign is night blindness (nyctalopia) which is an inability to
see under conditions of low light intensity. This is a result of an inadequate supply of retinol
to the rods which is required for the formation of 11-cis-retinal which forms part of the visual
pigment rhodopsin.
Conjunctival xerosis (XIA): The next stage progresses to signs seen in the outer eye where
there is a generalized drying up of the mucous membranes on the conjunctiva and the
invasion of the conjunctiva by capillaries. The conjunctiva takes on a wrinkled appearance
near the cornea, which appears dull instead of shiny. This process is called xerosis (drying
up) and is accompanied by the deposition of keratin plaques on the eye derived from
undifferentiated columnar epithelial cells.
Bitot Spots (XI B): Sometimes spots called bitot spots are seen on the conjunctiva; these have
a foamy appearance (Fig. 1). If as few as 1 per cent of children show clinical signs of vitamin
A deficiency in a population, it is considered a public health problem.
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Fig.1 Bitot spots on the conjunctiva

Advanced stages of VAD disorder (irreversible with permanent damage): Early stages of
VAD mentioned above are reversible if promptly treated with vitamin A, which is usually
administered in large doses of vitamin A supplements. If untreated, the disorder progresses to
cause keratomalacia which results in permanent scarring and is irreversible.
Corneal Xerosis (X2): marked by haziness or dryness of cornea. Cornea takes on a ground
glass appearance.
Corneal ulceration/ Keratomalacia (< 1/3 corneal surfaceX3A): Corneal ulcers are circular
and sharply demarcated. This may be also sometimes treatable.
Corneal ulceration/ Keratomalacia (>1/3 corneal surfaceX3B): Characterized by complete
death of tissue affecting the full thickness of the cornea, leading to complete blindness.
Corneal scar (XS) and Xerophthalmia fundus (XF) are some of the others classified
symptoms of VAD disorder.
Treatment and Prevention of VAD disorder

The most important step in preventing vitamin A deficiency is ensuring that children's diets
include adequate amounts of carotene containing cereals, tubers, vegetables, and fruits.
Strategy to mitigate VAD: An overall strategy designed to prevent and control vitamin A
deficiency, xerophthalmia, and nutritional blindness may be defined in terms of action taken
in the short, medium, and long term.
A short-term, emergency measure includes the administration to vulnerable groups of single,
large doses of vitamin A on a periodic basis.
In the medium-term, the fortification of a dietary vehicle (e.g., oil, sugar or monosodium
glutamate) with vitamin A can be initiated.
Long-term solution to this problem is through increased dietary intake of vitamin A through
home gardening and nutrition education programs.
National nutrition policy: Focuses on comprehensive approach in improved infant and child
feeding practices (IYCF), dietary diversification, supplementation, food fortification and
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horticultural intervention, exclusive breast feeding up to 6 months of age, promotion of

consumption of green, yellow-orange fruits and vegetables and linking vitamin A
supplementation to ICDS.
Massive vitamin A doses: Periodic delivery of mega-dose of vitamin A (200, 000 IU) is
given to children between 1-5 years of age.
Genetically modified foods (GM): Promotion of vitamin A foods is being visualised e.g.;
Golden rice-2 is a carotene rice has been announced. However, carotene rich GM foods are
currently not available.
Toxicity of vitamin A
Because the vitamin is stored in the liver, it is possible to develop a toxic condition when
very high (10 times normal intake) levels of the vitamin are consumed. The early reports of
vitamin A toxicity are from polar explorers who ate the polar bears’ livers, which are
particularly rich in vitamin A. Acute toxicity occurs when more than 200 mg (0.7 mmol) is
consumed by adults or more than 100 mg in children. As early as 1934, reports appeared in
the literature of vitamin A intoxication in humans, rats, and chicks. In chicks, the most
obvious clinical signs are a reduced growth rate, an encrustation of the eyelids, and a
reddening of the corners of the mouth. In rats, bone fractures are observed. These bone
fractures may be related to the unusual brittleness of the bone in hypervitaminosis. In
experimental animals, excess vitamin A intake during gestation results in congenital
malformations in the young.
Symptoms of Vitamin A toxicity: In humans, hypervitaminosis A is characterized by

increased intracranial pressure resulting in headaches, blurring of vision, and in young
children, a bulging fontanel. Hair loss and skin lesions, anorexia, weight loss, nausea,
vomiting, vague abdominal pain, and irritability are common symptoms. The acute symptoms
of vitamin A toxicity include vomiting, abdominal pain, anorexia, blurred vision, headache,
and irritability. Chronic toxicity can occur when 10 mg is consumed over periods of a month
or more. Symptoms include headache, muscle and bone pain, ataxia, skin disorders, alopecia,
liver toxicity, and hyperlipidaemia. Not all the chronic symptoms are reversible. Vitamin A is
teratogenic and pregnancy intakes should not exceed 3 mg/d. Vitamin A supplements should
not be taken during pregnancy due to risk of teratogenicity.
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Symptoms of Carotene toxicity: Because of the limitation in the conversion of β-carotene to

retinol, vitamin A intoxication is less likely with large intakes of carotene; however, reports
of yellowing of the skin of persons consuming large amounts of carrot juice have appeared.
There is no risk of toxicity from carotenoids in foods although large intakes can result yellow
discoloration of the skin. This yellowing is likely due to the deposition of carotene and
associated pigments in the subcutaneous fat.
Adverse effects of massive dose of vitamin A supplementation (MDVAS): Acute toxicity
following MDVAS in infancy has been reported across the globe. Effects are as follows:
Bulging fontanelle: Nearly 12% of infants developed bulging fontanelle, when administered
100,000 IU of vitamin A.
Vitamin A and vitamin D antagonism: Animal studies suggest that vitamin A is an antagonist
of vitamin D. Increasing the levels of retinyl acetate abrogates the ability of vitamin D to
elevate the level of serum calcium.
Potential for aggravation of zinc deficiency: There is a possibility that zinc deficiency, which
is already present in under-nourished children, could be aggravated by massive doses of
vitamin A.
Growth retardation: The administration of massive doses of vitamin A to children who may
be deficient in multiple nutrients including vitamin D and zinc could aggravate growth
retardation. Potential risk has to be carefully investigated. Risk of acute respiratory infection
Infection rate: Vitamin A administration has been associated with a significant increase in the
prevalence rate of pneumonia and upper respiratory infection in well-nourished children who
received 10,000 IU of vitamin A supplements weekly.
Hence, high dose vitamin A supplements are not recommended on a routine basis for all pre-
school children and should be offered only to individuals or populations with vitamin A
deficiency.
6.4. VITAMIN D
Vitamin D is also referred to as the sunshine vitamin. Skin exposure to sunlight for Asians is
10-15 minutes at noon during summers in winters higher exposure is needed to maintain
normal Vitamin D levels. In the previous century vitamin D deficiency was very common in
England especially in the industrial towns where the UV rays were screened out due to
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smoke. In India it was not considered a public health problem till recently, when biochemical
surveys showed otherwise. Among adults the prevalence of deficiency may be as high as
80%. It is now emerging as a public health problem due to several reasons.
Aetiology of vitamin D deficiency:
Despite abundant sunshine vitamin D deficiency is seen in India due to several reasons such
as:
Poor diets: poor diets (low calcium, high phytate, high fiber) despite exposure to sunshine can
cause low vitamin D deficiency.
Multiple and unplanned pregnancies will increase nutritional demand.
Maternal vitamin D deficiency willcompromise the vitamin D status of offspring
Lack of exposure to sunshine: long hours indoors prevent enough exposure to sunshine.
Changing work culture: This is one of the important contributory factors in high prevalence
of vitamin D deficiency.
Use of burqua and purdah: Vitamin D deficiency is more common among women opting for
this practice.
Effects of vitamin D deficiency

Vitamin D regulates of plasma calcium levels at three levels – absorption, renal reabsorption
and bone resorption. Vitamin D also has a role in GLA proteins synthesis (osteocalcin).
Recent research suggests it has role in modulation of psoriasis, TB, leukemia and cancers of
breast, prostate and colon. Deficiency of vitamin D results in, inadequate mineralization of
the bone due to calcium deficiency and increased secretion of PTH which in turn stimulates
bone resorption causing osteomalacia and rickets.
Rickets is a disease of toddlers, characterized by under mineralized bones as a result of poor

absorption of calcium in the absence of adequate amounts of calcitriol. The characteristic
signs of rickets are-
– Teeth may erupt in an abnormal manner and the enamel may be defective.
– Malformed pelvic bones in women cause serious difficulties in childbirth.
– Permanent crippling results if severe cases are not treated. Other abnormalities
associated with rickets are flabby muscles, and muscle spasms (in severe cases).
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– The deformities of rickets (curving and twisting of the bones from their normal shape)
are most likely to be found in the bones that bear the most weight or stress, such as
the leg bones. When the child begins to walk, the long bones of the legs are deformed,
leading to bow-legs or knock knees.
– Children display a protruding abdomen and beaded ribs (the so-called ‘rachitic
rosary’)
– Rickets can also lead to collapse of the ribcage and deformities of the bones of the
pelvis. Cranial bossing (thickening of parts of the skull), pigeon chest (the
breastbone or sternum is pushed backwards as it descends, forming a depression
between the ribs)
– Enlargement of the epiphyses. The epiphyses are the regions at the ends of the long
bones which are separated from the shaft of the bone, or diaphysis, by a layer of
cartilage called the epiphyseal plate. These regions are mineralized during growth and
eventually become part of the shaft of the bone.
Fig. 2: Effects of rickets

Similar problems may also occur in adolescents who are deficient in vitamin D during the
adolescent growth spurt, when there is again a high demand for calcium for new bone
formation.
Osteomalacia is the adult equivalent of rickets. It results from the demineralization of bone,
rather than the failure to mineralize it in the first place, as is the case with rickets. Women
who have little exposure to sunlight are especially at risk from osteomalacia after several
pregnancies, because of the strain that pregnancy places on their marginal reserve of calcium.
It may occur in elderly people also.
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Treatment and prevention of vitamin D deficiency

The principal treatment is to provide vitamin D and calcium supplements under medical
supervision. Prevention of vitamin D deficiency can be ensured by-
Exposure to sunlight: 30 minutes of exposure of arms and face (without sunscreen) to the
midday sun.
Dietary consumption: Consumption of milk and milk products are important for children. In
the absence of sufficient exposure to sunshine cod-liver oil should be given.
Nutrition education: Need for calcium and vitamin D should be emphasized. Women must be
told about the need for child spacing.
Fortification: Fortification of milk and milk products and other foods such as bread and oil
are useful in improving the vitamin D status.
Vitamin D toxicity
Toxicity is generally only seen with intakes are in excess of 250 µg/day. There clearly are
genetic disorders where infants show signs of vitamin D toxicity with lower intakes
(idiopathic hypercalcaemia). Few foods, with the possible exception of oily fish and fish
liver, supply sufficient amounts to result in toxic effects. Consequently, toxicity invariably
results from the excessive intake of vitamin D from supplementary sources. Excessive
vitamin D intake may lead to-
Hypercalcaemia (high blood calcium concentrations) and hypercalciuria (increased calcium
excretion).
Calcinosis (calcification of soft tissues, including the kidney, heart, lungs, and blood vessel
walls). Vitamin D toxicity results in the deposition of calcium in soft tissues and eventually
causes kidney damage.
High Blood pressure: Contraction of blood vessels, and hence dangerously high BP.
6.5. FOLIC ACID

Aeteology of folic acid deficiency
Folate deficiency can arise due to a number of factors-
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Poor dietary intake: Folate present in plant based Indian diets is less bioavailable (folate
polyglutamate). Exclusion of rich sources of folate such as leafy vegetables, pulses, meat and
liver in the diet. Processing and cooking also results in losses.
Increased demands: In pregnancy and growth folate requirement is high due to its role in
nucleic acid synthesis.
Infestations and infection: impair absorption.
Other factors: such as use of anticonvulsant drugs and tropical sprue can compromise folate
status in a person.
Deficiency of folic acid

Folic acid is needed for all one carbon transfer reaction and is responsible for purine and
pyrimidine nucleotide synthesis which are needed for rapidly growing cells. Folate is
required for nucleic acid synthesis. Folate and vitamin B-12 function are closely linked.
Vitamin B-12 coenzyme is required to recycle the folate coenzyme needed for DNA
synthesis. Thus, folate and vitamin B-12 deficiencies can produce identical signs and
symptoms. General symptoms of iron deficiency are present which confuses the field health
worker further. Anaemia can also be caused by deficiencies of folate and/or vitamin B12. In
this case, the number of RBC formed is decreased and they are packed full of haemoglobin.
This is called a macrocytic anaemia and the Mean Corpuscular Volume is > 95fL. However,
it is not possible to classify an anaemia precisely from examining the blood film. If a bone
marrow biopsy is conducted megalobasts will be seen, this is why these anaemias are called
megaloblastic. Megaloblastic anaemia can occur in late pregnancy as a consequence of folate
deficiency. It can also occur because of a combination of dietary vitamin B12 and folate
deficiency, especially in vegetarians of South Asian ethnic origin. The symptoms such as
weakness, tiredness, dyspnea, sore tongue, diarrhea, irritability and forgetfulness, anorexia,
headache and palpitation are present. Neural Tube Defect (NTD) along with megaloblastic
anemia are a serious public health problem.
Neural tube defect: Folate is needed for differentiation of stem cell to various types of blood
cells. When embryo is 2-3 mm long a flat structure called the neural plate forms two parallel
ridges. These ridges fold over more to form a tube (neural tube). Drugs, nutrient imbalance or
genetic defect may prevent normal closure and this results in NTD causing disorders such as,
spina bifida, anencephaly (no brain), encephalocele (tissue producing through a hole in skull).
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Role of folate in preventing NTD: Folate supplementation has been demonstrated to alleviate
the effects of deficiency-
– John Scott and Co-workers in 1995 collected 56,000 blood samples from women
attending prenatal clinics in Ireland and found a negative association between intake
folic acid and NTD.
– In a prospective study China 2,50,000 women, were supplemented with 400 μg of
folic acid during peri-conceptional period. Due to this rate of NTD decreased by 85
and 40% in North and South China respectively.
Treatment and prevention of folic acid deficiency

Dietary approach: Promotion of rich sources of folate such as leafy vegetables, pulses, meat
and liver in the diet of most vulnerable segment i.e., women of reproductive age and children.
Supplementation: For preventing anaemia National Nutritional Anemia Control Program
(NNACP) in India, aims at decreasing the prevalence and incidence of anaemia in women of
reproductive age. Pregnant women are recommended to have one big tablet per day for 100
days after the first trimester of pregnancy; a similar dose applies to lactating women.
Preschool children (ages 1-5 years) are recommended to take one small tablet per day for 100
days every year. Adult tablets contain 100 mg iron and 500 µg folic acid, while paediatric
tablets contain 20 mg iron and 100 µg folic acid.
Toxicity of Folate
Exacerbation of B12 deficiency: Folate deficiency and B12 deficiency both cause anaemias,
conditions in which the body is unable to make enough healthy red blood cells. Taking a folic
acid supplement for folate deficiency can temporarily alleviate the symptoms of a
B12 deficiency, allowing it to go untreated. Folic acid – 4.0 mg/day to reduce NTD prevents
detection of pernicious anaemia. Folic acid supplements can mask signs of anaemia due to
B12 deficiency but may aggravate the neurological symptoms.
6.6. VITAMIN B12

Deficiency of vitamin B12
Vitamin B12 is essential for cognition, the nervous system, vascular health, and red blood
cell synthesis. The prevalence of vitamin B12 deficiency increases with age, mainly because
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of decreased ability to digest the natural chemical form of vitamin B12 found in animal
foods. Absorption is low in older adults who have atrophic gastritis, which is caused by
infection of the stomach with Helicobacter pylori and subsequent atrophy of the cells in the
stomach that secrete acid and digestive enzymes needed for the digestion and absorption of
vitamin B12.
Pernicious anaemia is a term used to describe the megaloblastic anaemia resulting from a
failure to absorb vitamin B12 due to loss of the intrinsic factor.
Treatment of Vitamin B12 deficiency

Treatment of pernicious anaemia must be under medical supervision, vitamin B12 status in
these individuals is maintained by monthly injections of vitamin B12 or daily oral doses of
500 to 2000 μg. Patients have to be treated with regular injections of vitamin B12 every 6
weeks or so. If they are given folic acid, it cures the anaemia and allows the more insidious
neurological symptoms of vitamin B12 deficiency to progress. In order to distinguish
between deficiencies of folate and vitamin B12, the concentrations in blood can be measured.
Vitamin B12 toxicity

An overdose of vitamin B12 is almost impossible. Vitamin B12 toxicity due to overdosage
does not occur. The only known side effect is a form of acne, which is still very rare.
6.7. THIAMINE
Aetiology of thiamine deficiency Thiamine deficiency may arise due to inadequate intakes
and alcoholism.
Inadequate intake: Relatively higher energy intakes of foods deficient in thiamine.
Consumption of polished rice has historically contributed to large epidemics of beriberi that
appeared at the end of the nineteenth century, with the advent of the mechanical milling of
rice. It was caused by over-reliance on a single staple food, polished rice and lack of variety
in the diet. This situation is relatively rare nowadays
Alcoholism: Thiamine deficiency is becoming increasingly common amongst alcoholics in
all countries. Here it is due to a monotonous diet of alcoholic beverages, which contain little
thiamine, combined with alcohol-induced damage to the intestine, affecting absorption, and
to the liver, affecting phosphorylation of thiamine.
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Effects of thiamine deficiency

Thiamine acts in the body as Thiamine Pyro phosphate (TPP) which is a cofactor in enzymes
required for carbohydrate metabolism. Deficiency of TPP in the Pyruvate dehydrogenase –
Glycolytic pathway and the transketolase – Pentose Phosphate shunt results in pyruvate and
lactic acid accumulation. Apart from its role in carbohydrate metabolism thiamine is required
for catabolism of branched chain amino acids (leucine, isoleucine, valine). Thiamine Tri
phosphate (TTP) has a role in maintaining cell membranes and restores the action potential of
UV ray damaged isolated nerves. Because of wide ranging functions in the body its
deficiency causes several effects such as:
– Anorexia, weight loss, arrhythmia of heart, neurological symptoms.
– Oedema
– Heart defects – Tachycardia, enlarged heart, cardiac failure.
– Neurological defects - quivering of hands and limbs (ataxia), – Paralysis of eye
(nystagmus) and muscle twitching.
– Polyneuropathy- Peripheral and optic neuropathy.
Severe thiamine deficiency resulting in beriberi is rare nowadays. Several distinct forms of
beriberi have been described. Symptoms of more than one form may occur in a single patient.
Dry beriberi is the chronic form, and is characterized by a progressive peripheral neuropathy.
This leads to muscle wasting which is the prominent sign. Symptoms include a burning
sensation, muscle cramps and stiffness in the legs, then numbness which starts in the fingers
and toes and gradually spreads centrally. Loss of motor function follows loss of sensation,
and this in turn leads to muscle wasting.
Wet beriberi is recognized as the acute form. Peripheral oedema is the most prominent sign,
and is usually accompanied by anorexia. Death may occur through heart failure, because of
an inability to clear the fluid load.
Acute cardiac beriberi (shoshin) is characterized by cardiac hypertrophy and weakness in the
absence of neuropathy or significant oedema. The main signs are breathlessness and
palpitations.
Acute infantile beriberi causes anorexia, tenderness, oedema, then tachycardia and
tachypnoea and ultimately death from heart failure. This form is likely to be found among
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infants who are being breastfed by a mother with marginal thiamine status who may have
shown no signs of deficiency herself, but her breast milk thiamine content would be low.
Wernicke-Korsakoff syndrome: deficiency caused due to alcoholism, hunger strike, persistent
vomiting has been identified as the cause of the Wernicke-Korsakoff syndrome. Wernicke’s
encephalopathy involves nystagmus (rapid, jerky eye movements), confusion, muscle
weakness and ataxia, giddiness and anorexia. It can be rapidly reversed by thiamine
injections, but may progress to an irreversible stage. In Korsakoff’s psychosis the sufferer is
unable to form new memories, and may try to hide this by making up wild stories
(confabulation). This syndrome is medically treated with a high dose of thiamine. Permanent
memory loss occurs if not treated.
Prevention and treatment of thiamine deficiency disorders
General improvement in diet to include better sources of thiamine. Following good cooking
practices like parboiling of rice and avoiding adding cooking soda should be practiced.
Alcohol intake should be avoided or if necessary, then regulated. Care should be taken about
ensuring that alcohol is not the main source of energy.
Beriberi and Wernicke’s syndrome can be treated by 10-20 mg of thiamine parenterally twice
or thrice a day.
Toxicity of thiamine intake

Adverse reactions with thiamine are rare. Thus, up to 100mg/day are apparently safe.
6.8. NIACIN
Aetiology of pellagra
Deficiency is seen predominantly among poor people in South Africa whose staple is maize
(pellagra is called as maize eaters’ disease). This is because maize is deficient in both niacin
and also tryptophan. Niacin in maize is in the form of niacytin which is unavailable for
absorption in the human gut (this also applies to most other cereals as well) and the main
protein in maize, zein, is almost devoid of tryptophan.
In India it is seen among those who consume sorghum as their staple. Among poor
population whose staple food is sorghum the disease pellagra occurs due to an imbalance of
amino acids. Amino acid imbalance results in inhibition of conversion of tryptophan to niacin
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and inhibition of niacin to NAD by preventing conversion of quinolinate (depicted in the flow
chart below).
Effects of deficiency
Pellagra is a deficiency disease that is primarily a consequence of an inadequate intake of
niacin and/or tryptophan. Lack of niacin affects the skin, gastrointestinal tract and the central
nervous system. Pellagra is often referred to as the deficiency disease of the three Ds –
dermatitis, diarrhoea and dementia.
Dermal lesions: Pphotosensitive rashes appear on the skin which are characterized by
bilateral skin lesions. Skin exposed to sun is most affected – hands, face. The skin on the
neck, chest, may become brown and scaly and forms the pattern of necklace (casal’s
necklace).
GI changes (Diarrhea): Initial symptoms include a smooth, red tongue (glossitis) , a sore
mouth (stomatitis) and ulceration of the inside of the cheeks. The diarrhoea is caused by
damage to the epithelial lining of gut, and if present is likely to cause other nutrient
deficiencies. Mucous membrane is inflamed.
Neurological manifestations: Dementia is the most serious consequence. It starts with
headaches, vertigo, insomnia and depression and progresses through hallucinations to
delirium, convulsions and death. Higher mental function is deranged. Decreased serotonin
levels, acute encephalopathy and abnormal electroencephalogram readings may be observed.
Treatment of Pellagra
Pellagra can be cured by a good diet containing adequate amounts of protein, tryptophan,
niacin as well as other members of B-complex group of vitamins. Although milk is poor in
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nicotinic acid content it is effective in preventing pellagra because it is rich in essential amino
acid tryptophan.
Niacin toxicity
Mega doses 1.3g-3g thrice daily to treat schizophrenia and high blood cholesterol levels.
Niacin mega doses are associated with a host of untoward effects such as flushing of the face,
neck and chest; abnormal heart rhythms; itching; headache; cramps; nausea and vomiting;
diarrhea; abnormally low blood pressure; fast heartbeat, and elevated blood sugar.
Larger doses (3–6 g/d) cause reversible liver toxicity with changes in liver function,
carbohydrate tolerance, and uric acid metabolism.
6.9. VITAMIN B6 (PYRIDOXINE)

Pyridoxine is part of PMP and PLP which are cofactors in several coenzymes that participate
in erythrocyte formation and haem synthesis. They are also needed for synthesis of nucleic
acids, histamine, catecholamines and several hormones such as thyroid, adrenal, neuro
hormones and insulin.
Pyridoxine deficiency
Deficiency is not very common. However, consumption of highly processed and refined
foods particularly among poor segment of population can result in deficiency. Alcoholism is
another probable cause of deficiency.
Severe deficiency results in oral, dermatological and neurologic changes. Peripheral neuritis,
glossitis, cheilosis, sebhorric dermatitis. Hypochromic microcytic anaemia in the presence of
high serum iron levels may be seen. Impaired immune response leading to secondary
infection is observed.
Deficiency symptoms can be cured with supplements usually 10 to 20 mg per day.
Toxicity of vitamin B6
Intakes of 50 mg/d and above have been associated with peripheral neuropathy and loss of
sensation in the feet has been reported at higher doses (from supplements). Peripheral
neuropathy which appears to be reversible if the use of the supplement is ceased in time.
Large doses of pyridoxine (2–3 g/d) can cause permanent nerve damage. Symptoms include
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tingling in the hands and feet, a stumbling gait, numbness around the mouth, a characteristic
‘stocking-glove’ sensory loss and lack of muscle coordination. The safe upper limit of daily
dose of vitamin B6 should not exceed 10 mg/d.
6.10. RIBOFLAVIN
Aetiology of riboflavin deficiency
Riboflavin deficiency due to inadequate intake is widespread in India particularly in rural
areas According to some biochemical studies deficiencies of riboflavin was common. High
prevalence of respiratory tract infection has been observed to be associated with riboflavin
deficiency. Negative nitrogen balance increases urinary loss while exercise leads to an
increase in riboflavin demands. Riboflavin deficiency is seen associated with prolonged
fevers, trauma, malabsorption, hyperthyroidism and malignancy.
Symptoms of Riboflavin deficiency

The well-established clinical signs of riboflavin deficiency are-
Muco-cutaneous lesions of the mouth- angular stomatitis, glossitis, cheilosis. In severe
deficiency other areas like scrotum are also involved.
Impaired psychomotor performance: This is a less recognized consequences of riboflavin
deficiency. Haematological manifestations: There is reduced iron absorption due to lower
conversion of ferric iron to ferrous iron, and subsequently there is risk of anaemia.
Reduced skin collagen maturity is another not so well-known symptoms of riboflavin
deficiency.
Diminished visual acuity can also be attributed to riboflavin deficiency. Photophobia is a
classic symptom.
Prevention and treatment

General improvement in diet to include better sources of riboflavin. Following good cooking
practices like avoiding the exposing foods to sunlight and adding cooking soda should be
practiced.
Treatment involves oral supplements of 5-10mg per day to cure oral and dermal lesions. Oral
supplements are given to new-borns undergoing photo therapy.
KSOU, Mysuru. 133

Toxicity
Riboflavin toxicity is low due to the small amount that can be absorbed by the
gastrointestinal tract in a single dose.
6.11. TOXICITY OF OTHER VITAMINS

Vitamin E toxicity: Vitamin E has low toxicity but at very high doses it acts as an antagonist
to vitamins A, D, and K. Symptoms of toxicity include headache, nausea, muscle weakness,
double vision, and creatinuria, and gastrointestinal disturbances.
Vitamin K toxicity: Large intakes of naturally occurring vitamin K do not appear to be toxic.
Synthetic preparation of vitamin K3 (menadione) is used to treat intracranial and pulmonary
haemorrhage in premature infants and overdosage can cause liver overload and brain toxicity.
Supplements containing vitamin K should not be taken when taking anticoagulant drugs, e.g.
warfarin.
Vitamin C toxicity: High doses (1–10 g/day) of vitamin C are sometimes taken in the belief
that such doses can prevent the common cold. There is no evidence to support this hypothesis
although they may reduce the severity of symptoms to an extent. Sudden cessation of high
dose supplements may precipitate rebound scurvy. Intakes at such high levels have been
associated with diarrhoea and increased risk of kidney oxalate stone formation.
CHECK YOUR PROGRESS
i. What is TUL?
ii. What are the causes of VAD?
iii. What may be the adverse effects of massive dose of vitamin A?
iv. Describe the effects of vitamin D deficiency.
v. Explain the term neural tube defect.
vi. Why does taking folate supplements sometimes increases effects of vitamin B12
deficiency?
vii. Explain the term Wernicke-Korsakoff syndrome.
viii. How can pellagra be treated?
ix. Explain the effects of niacin toxicity.
x. Explain the effects of vitamin B6 toxicity.
xi. What are the effects of riboflavin deficiency?
KSOU, Mysuru. 134

Fill in the blanks

i. A plasma or serum retinol concentration ___________mol/L indicates subclinical
vitamin A deficiency in children and adults, and a concentration of __________
µmol/L indicates severe vitamin A deficiency.
ii. Massive vitamin A dose consists of periodic delivery of mega-dose of ____________
IU vitamin A to children between 1-5 years of age.
iii. Vitamin D toxicity resulting in the deposition of calcium in soft tissues is known as
____________.
iv. Folate and vitamin ___________ function is closely linked.
v. Pellagra is can be prevalent among people whose staple is either _____________or
___________________.
6.12. SUMMARY
The ecology of common nutritional deficiencies and nutrient toxicities was described in this
unit. Inadequate supply or variety of foods is the overriding reason why dietary deficiencies
of different nutrients occur. Infections have a strong association either as the reason for their
cause or an outcome of deficiency disorder. Deficiency diseases of only vitamin A, vitamin
D, thiamine, riboflavin, niacin, folate and vitamin B12 result in widespread public health
problems. Deficiencies of the remaining vitamins are rare. Adverse effects resulting from the
overconsumption of some vitamins, especially of retinol, vitamin D and vitamin B6 which
can be toxic due to risk of overconsumption of vitamins as several foods are now being
fortified with nutrients. The knowledge of Tolerable Upper Limit (TUL) of intake for
nutrients helps us to safe guard against over consumption of nutrients. Micronutrients,
especially the vitamins, can themselves be drugs when taken to excess. In this section
deficiency symptoms and its aetiology, prevention and treatment of vitamins is explained.
Toxicity arising from effects of high intakes of vitamins is also explained.
6.13. GLOSSARY
Aetiology The cause, set of causes, or manner of causation of a disease or
condition.
Haemopoiesis The growth and maturation of the blood cells and other formed blood
KSOU, Mysuru. 135

elements in the bone marrow.

Cornea The cornea is the transparent front part of the eye that covers the iris,
pupil, and anterior chamber.
Conjunctiva The mucous membrane that covers the front of the eye and lines the
inside of the eyelids.
Intracranial pressure The pressure exerted by the brain, cerebrospinal fluid (CSF), and the
brain’s blood supply on closed intracranial space or the skull.
Teratogenicity Cancer producing effect
GLA proteins These are γ-carboxyglutamic acid protein, or matrix GLA protein, are a
highly insoluble protein of bone.
PTH Parathyroid hormone. It is a protein hormone released by the parathyroid
gland. The parathyroid hormone stimulates the following
functions: Release of calcium by bones into the bloodstream. Absorption
of calcium from food by the intestines. Conservation of calcium by the
kidneys.
Calcitriol Calcitriol, is actually the most active form of vitamin D
Folate polyglutamate Dietary folate consists of monoglutamate and polyglutamate folate
species. In the small intestine, folate polyglutamate is deconjugated to
the monoglutamate form before absorption takes place. This enzymatic
deconjugation might limit the bioavailability of polyglutamate folate.
Megaloblasts RBCs are larger than normal. Folate or vitamin B12 deficiency causes
this kind of abnormality in the red blood cells.
Intrinsic factor The intrinsic factor is a glycoprotein produced by the parietal cells
located at the gastric lining of stomach. Intrinsic factor plays a crucial
role in the transportation and absorption of the vital micronutrient
vitamin B12 by the terminal ileum.
Helicobacter pylori Helicobacter pylori is a type of bacteria which can enter into the
digestive tract. After many years, they can cause sores, called ulcers, in
the lining of the stomach or the upper part of small intestine.
Arrhythmia A heart arrhythmia is an irregular heartbeat.
Tachycardia Tachycardia is the medical term for a heart rate over 100 beats a minute.
Tachypnoea It is abnormally rapid breathing.
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Neuropathy It is the disease or dysfunction of one or more peripheral nerves,

typically causing numbness or weakness.
Photosensitive A condition characterised by sensitivity to sunlight or other forms of
ultraviolet light.
2. Carolyn D. Berdanier, 1998, Advanced nutrition, CRC Press, Printed in the United
States of America
3. Recommended dietary allowances and estimated average requirements nutrient
requirements for indians – 2020, A Report of the Expert Group Indian Council of
Medical Research National Institute of Nutrition, ICMR, New Delhi.
4. Umesh Kapil, 2018, Massive Dose Vitamin A Supplementation (MDVAS) to
Children in India: is there enough evidence to continue the programme?, NFI
bulletine, Volume 39, Number 2
ANSWER TO CHECK YOUR PROGRESS Answer the following

i. What is TUL?
The TUL is the maximum level of habitual intake from all sources of a nutrient or related
substance judged to be unlikely to lead to adverse health effects in humans
ii. What are the causes of VAD?
Poor diets
Low purchasing power
Ignorance
Availability of some of the carotene rich foods may be affected by season.
Infection
Protein Energy Malnutrition (PEM)
iii. What may be the adverse effects of massive dose of vitamin A?
Acute toxicity following massive dose of vitamin A in infancy are- Bulging fontanelle,
vitamin A and vitamin D antagonism, potential for aggravation of zinc deficiency, growth
retardation and an increased infection rate. Hence, high dose vitamin A supplements are not
KSOU, Mysuru. 137

recommended on a routine basis for all pre-school children and should be offered only to
individuals or populations with vitamin A deficiency.
iv. Describe the effects of vitamin D deficiency.
Vitamin D regulates of plasma calcium levels at three levels – absorption, renal reabsorption
and bone resorption. Vitamin D also has a role in GLA proteins synthesis (osteocalcin).
Recent research suggests it has role in modulation of psoriasis, TB, leukemia and cancers of
breast, prostate and colon. Deficiency of vitamin D results in, inadequate mineralization of
the bone due to calcium deficiency and increased secretion of PTH which in turn stimulates
bone resorption causing osteomalacia and rickets.
v. Explain the term neural tube defect.
When embryo is 2-3 mm long a flat structure called the neural plate forms two parallel
ridges. These ridges fold over more to form a tube (neural tube). Drugs, nutrient imbalance or
genetic defect may prevent normal closure (NTD) resulting in Spina bifida, anencephaly (no
brain), encephalocele (tissue producing through a hole in skull).
vi. Why does taking folate supplements sometimes increases effects of vitamin B12
deficiency?
Folate deficiency and B12 deficiency both cause anaemias, conditions in which the body is
unable to make enough healthy red blood cells. Taking a folic acid supplement for
folate deficiency can temporarily alleviate the symptoms of a B12 deficiency, allowing it to
go untreated. Folic acid – 4.0 mg/day to reduce NTD prevents detection of pernicious
anaemia. Folic acid supplements can mask signs of anaemia due to B12 deficiency but may
aggravate the neurological symptoms.
vii. Explain the term Wernicke-Korsakoff syndrome.
Deficiency of thiamine caused due to alcoholism, hunger strike, persistent vomiting has been
identified as the cause of the Wernicke-Korsakoff syndrome. Wernicke’s encephalopathy
involves nystagmus (rapid, jerky eye movements), confusion, muscle weakness and ataxia,
giddiness and anorexia. It can be rapidly reversed by thiamine injections, but may progress to
an irreversible stage, Korsakoff’s psychosis. Here the sufferer is unable to form new
memories, and may try to hide this by making up wild stories (confabulation). This syndrome
is medically treated with a high dose of thiamine. Permanent memory loss occurs if not
treated.
viii. How can pellagra be treated?
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Pellagra can be cured by a good diet containing adequate amounts of protein, tryptophan,
niacin as well as other members of B-complex group of vitamins. Although milk is poor in
nicotinic acid content it is effective in preventing pellagra because it is rich in essential amino
acid tryptophan.
ix. Explain the effects of niacin toxicity.

Mega doses 1.3g-3g thrice daily to treat Schizophrenia and high blood cholesterol levels.
Niacin mega doses are associated with a host of untoward effects such as flushing of the face,
neck and chest; abnormal heart rhythms; itching; headache; cramps; nausea and vomiting;
diarrhea; abnormally low blood pressure; fast heartbeat, and elevated blood sugar.
Larger doses (3–6 g/d) cause reversible liver toxicity with changes in liver function,
carbohydrate tolerance, and uric acid metabolism.
x. Explain the effects of vitamin B6 toxicity.

Intakes of 50 mg/d and above have been associated with peripheral neuropathy and loss of
sensation in the feet has been reported at higher doses (from supplements). Peripheral
neuropathy which appears to be reversible if the use of the supplement is ceased in time.
Large doses of pyridoxine (2–3 g/d) can cause permanent nerve damage. Symptoms include
tingling in the hands and feet, a stumbling gait, numbness around the mouth, a characteristic
‘stocking-glove’ sensory loss and lack of muscle coordination. The safe upper limit of daily
dose of vitamin B6 should not exceed 10 mg/d.
xi. What are the effects of riboflavin deficiency?

The clinical signs of riboflavin deficiency are-
– Muco-cutaneous lesions of the mouth- angular stomatitis, glossitis, cheilosis.
– Impaired psychomotor performance
– Haematological manifestations: There is reduced iron absorption due to lower
conversion of ferric iron to ferrous iron, and subsequently there is risk of anaemia.
– Reduced skin collagen maturity
– Diminished visual acuity and photophobia
–
KSOU, Mysuru. 139

Fill in the blanks

i. A plasma or serum retinol concentration <0.70 μmol/L indicates subclinical vitamin A
deficiency in children and adults, and a concentration of <0.35 µmol/L indicates
severe vitamin A deficiency.
ii. Massive vitamin A dose consists of periodic delivery of mega-dose of 200, 000 IU
vitamin A to children between 1-5 years of age.
iii. Vitamin D toxicity resulting in the deposition of calcium in soft tissues is known as
calcinosis.
iv. Folate and vitamin B-12 function are closely linked.
v. Pellagra is can be prevalent among people whose staple is either Maize or Jowar.
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UNIT-7: MINERAL DEFICIENCY AND TOXICITY
STRUCTURE
7.1. OBJECTIVES
7.2. INTRODUCTION
7.3. CALCIUM
7.4. IRON
7.5. IODINE
7.6. ZINC
7.7. FLOURIDE
7.8. TOXICITY OF OTHER MINERALS
7.9. SUMMARY
7.10. GLOSSARY
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7.1. OBJECTIVES

 Describe the symptoms of deficiency of minerals
 Understand ways to prevent and treat deficiency disorders
 Describe the effects of excess of mineral intakes
7.2. INTRODUCTION
The body needs a variety of nutrients to stay healthy which is obtained from a balanced diet. Minerals
are needed in balanced proportions. Minerals interactions in foods, digestive tract and within the body
play a significant role in the way they are absorbed and function in the body. Mineral interactions are
an important criterion in determining their physiological need for a person. The physiological state
(e.g., pregnancy, infancy etc.) also decide the amount of minerals needed by an individual. In
physiological conditions like pregnancy and lactation, adult woman needs additional nutrients to meet
the demand for foetal growth and maternal tissue expansion in pregnancy and milk secretion during
lactation. These extra intakes of nutrients are essential for normal growth of infants in utero and
during early post-natal life. Individuals who abuse alcohol and eat a poor diet are at increased risk of
mineral deficiencies as well. Deficiencies of calcium, magnesium, zinc, and iron are most common
due to poor absorption.
Nowadays individuals may be increasingly relying on pharmaceutical nutrient supplements. This may
lead to overconsumption of minerals which may be toxic or create unhealthy interactions with other
minerals, e.g., too much calcium can hinder absorption of zinc and iron. Therefore, Indian council of
medical research (ICMR) has introduced tolerable upper limits (TUL). TUL Refers to the highest
average daily nutrient intake level that is likely to pose no risk of adverse health effects to almost all
individuals in the general population. As intake increases above the TUL, the risk of adverse effects
will increase. Table 1 shows the TUL for some minerals. Potentially all minerals are poisonous when
consumed in excess and their toxicity depends to a greater extent on their solubility. For example,
potassium and sodium salts are relatively more toxic compared with calcium salts. In practical terms,
toxicities of iron and the heavy metals are of the greatest significance.
TABLE 1: TOLERABLE UPPER LIMIT (TUL) FOR MINERALS (ICMR 2020)
Age Calcium Magnesium* Iron Zinc Iodine
(mg/ d) (mg/d) (mg/d) (mg/d) (µg/day)
Men 2500 350 45 40 1100
Women 2500 350 45 40 1100
*Note: TUL values are only for non-dietary pharmacological doses
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7.3. CALCIUM
Calcium is an important part of the mineral apatite of bones and teeth; it is important for metabolic
regulation and the transport of metabolites from one compartment to another. Calcium is needed for
apoptosis and in muscle contraction. Calcium needs of the body are determined by the physiological
sate and its interaction with other nutrients. High salt (sodium) diets have a negative consequence on
the bone density. Diets with a protein-calcium ratio of 16:1 and phosphorous-calcium ratio of 1:1 is
considered optimum for absorption and retention. Indians predominantly consume a vegetarian diet,
in such dietaries apart from milk other rich sources among plant foods are ragi (Eleusine coracana),
rajkeera (grain Amaranthus) and the green leafy vegetables. The main source of dietary calcium
across the population in India has been from non-dairy sources.
Prevalence of calcium deficiency
In developing countries where milk intake is low, most dietary calcium comes from cereals. Since
these are only a moderate source, the daily intake of Ca in such communities is in a low range of 300-
600 mg a day. In India, there is dietary calcium deficiency across various age groups and gender
coupled with vitamin D deficiency.
Aetiology
Small metabolic pool relative to large skeletal reserve does not allow metabolic deficiency to occur.
Blood calcium levels are maintained at the expense of skeletal mass. This is because a short-term
dietary inadequacy causes the body to adjust its blood calcium levels through-
 Increased reabsorption of calcium from distal tubule,
 Increased absorption from intestines and intestinal production of 1,25(OH)2D3
 Resorption of bone
However, continual inadequate intake or poorer intestinal absorption of calcium can occur due to vit
D deficiency will cause stress to the bones. Lack of vitamin D activation, loss of estrogen production,
adrenal dysfunction and parathyroid gland dysfunction can also result in calcium deficiency status.
There is concern that women from low-income group are exposed to a greater risk of developing bone
abnormalities due to poor nutrition and their occupational or nonoccupational activity aggravating the
situation. Current level of consumption providing less than 400 mg Ca/d is not able to protect them
from poor bone health and some segments of the population exhibit bone density (spinal) z-scores
described as osteoporotic.
Effects of deficiency
Calcium intakes are particularly important during growth and development. Attaining peak bone
densities is essential to prevent osteoporotic fractures in later life. Also attaining optimal accretion
KSOU, Mysuru. 143

rate of bone mass during puberty is critical for optimum body size and skeletal maturity. Cumulative
effect of calcium depletion are as follows:
 Inadequate bone calcification and growth in children (rickets) and weak porous bones in
adults (osteoporosis).
 Increased frequency of osteoporotic fractures with age.
 Decrease rate of skeletal accretion prevents attainment of genetically determined maximal
peak bone mass.
 May also play a role in etiology of – Hypertension, Preeclampsia and Colon cancer
 Should blood calcium levels fall acutely, calcium tetany will result, and unless calcium is
provided quickly by the intravenous route, death will ensue
Osteoporosis
Osteoporosis is defined by the World Health Organization (WHO) in women as a bone mineral
density 2.5 standard deviations below peak bone mass (20-year-old healthy female average).
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone
mineral density (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety of
proteins in bone is altered.
Prevention and treatment
Regular exercise and a healthy diet with enough calcium help teen and young adult White and Asian
women maintain good bone health and may reduce their high risk of osteoporosis later in life.
Adequate calcium intakes are important, but daily intakes above 2000 mg are not likely to provide any
additional benefit.
Osteoporosis prevention: Nutrition recommendations to prevent osteoporosis are: Calcium intake
1000–1500 mg/day permits normal growth and development of the skeleton, maximizes peak bone
mass, maintains adult bone mass, minimizes age-related bone loss and enhances benefits of
pharmacological therapy. Vitamin D supplements 600–1200 IU/day are recommended. Intake of
calcium/vitamin D should be maintained throughout life, starting before adolescence. Increase
awareness in children and adolescents of needed behavioural/ nutritional measures, as peak bone mass
occurs at an early age. Supplements of magnesium, 450–500 mg/day are recommended if tolerated.
Fall prevention in elderly is very important.
Prevention at community level: There has not been much emphasis on calcium as a supplement, in
micronutrient supplementation or food fortification programs in India. The Indian social safety net
program (SSNP) is a platform to address three major nutrition and feeding programs; viz. ICDS, Mid–
Day–meals scheme (MDM) and Targeted public distribution system (TPDS), that are providing food
supplements or food grains at community-level. These programs help in increasing cereal intake
which can contribute to moderate increase in calcium intakes
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Improving bioavailability of calcium: Cereals are the main contributors of calcium in vegetarian
Indian diets; thus, bioavailability plays an important role. Methods to enhance the bioavailability of
calcium and to reduce phytic acid content of the grains are: a) sprouting – lowers phytate and
improves extractability of calcium after 4 days of germination and reduces phytic acid content to
undetectable levels, b) flour made from whole grains have higher calcium content(325 mg/100 g)
compared to decorticated ones (222 mg/100 g), c) fermentation reduces the phytic acid levels by
72.3% and 54.3% after 96 and 72 h, and, d) other methods, as co-fermenting with horse gram
increases the nutritive value.
Assessment of calcium status
With the advent of Dual-energy X-ray absorptiometry (DEXA), estimation of assessing bone health
indicators in a non-invasive manner over a long period at multiple time-points has become possible,
wherein bone mineral content and densities were measured in the whole body and at four sites using
DEXA. The indicators used are, bone mass density (BMD) (g/cm2), Hip BMD (g/cm2), Forearm
BMD (g/cm2), Spine BMD (g/cm2).
Toxicity
Compared with other metals, the calcium ion and most calcium compounds have low toxicity. This is
not surprising given the very high natural abundance of calcium compounds in the environment and in
organisms. Excessive consumption of calcium carbonate antacids/dietary supplements over a
prolonged period of weeks or months can cause milk-alkali syndrome, with symptoms ranging from
hypercalcemia to potentially fatal renal failure ICMR recommended a TUL of 2500 mg as the upper
limit for Indian adults. High oxalate foods in plant-based diets might also increase the risk of
nephrolithiasis (kidney stones). Further, high calcium intakes might also interfere with absorption of
iron and zinc and may exacerbate their deficiency.
7.4. IRON
Iron plays an important role in oxygen exchange in the body through its presence as several types of
metalloproteins - haemoglobin, myoglobin, cytochromes, transferrin, ferritin, and a variety of other
iron binding proteins. Iron is called as one way nutrient, due to the fact that, iron use and reuse is very
efficient, and iron loss comprises a system that does not allow the body to be rid of it; the body
conserves its iron very tightly. Presence of tannins, phytates fibres, carbonates, phosphates, and low-
protein diets also adversely affect the absorption of iron. While, ascorbic acid, fructose, citric acid,
high-protein foods, lysine, histidine, cysteine, methionine, stearic acid and natural chelates, i.e., haem
KSOU, Mysuru. 145

all enhance the apparent absorption of iron. Zinc and manganese reduce iron uptake and conversely
excess iron reduces zinc uptakes.
Prevalence of iron deficiency
Anaemia is the most prevalent nutritional disorder worldwide and in India. It is defined in terms of
haemoglobin concentrations of less than 13 g/dl in men and 11.0 g/dl in women. Prevalence of
anaemia among children and adults in India is shown in Table 2.
TABLE 2: ANAEMIA AMONG CHILDREN AND ADULTS IN INDIA
NFHS-5 (2019- NFHS-4 (2015-16)

Category 21)
Urban Rural Urban Rural
(%)
Children age 6-59 months (Hb<11.0 g/dl) 64.2 68.3 67.1 58.6
Non-pregnant women age 15-49 years (Hb<12.0 g/dl) 54.1 58.7 57.2 53.2
Pregnant women age 15-49 years (Hb<11.0 g/dl) 45.7 54.3 52.2 50.4
All women age 15-19 years (Hb<12.0 g/dl) 56.5 60.2 59.1 54.1
Men age 15-49 years (Hb<13.0 g/dl) 20.4 27.4 25.0 22.7
Men age 15-19 years (Hb<13.0 g/dl) 25.0 33.9 31.1 29.2
Aetiology
The most common cause of anaemia is an inadequate supply of iron in the diet. Women during their
reproductive years are more at risk than men because of blood losses caused by menstruation. Iron
deficiency anaemia is almost twice as prevalent in vegetarians as in omnivores. This is because plant
sources of iron are less well absorbed than animal sources. Poor dietary habits particularly among
adolescence and early adulthood, milk-based diets in infants, menorrhagia, pregnancy, chronic
inflammatory condition especially in elderly and poor absorption and abnormal blood losses causes
iron deficiency anaemia. Three broad causes of iron deficiency are:
i. Poor iron absorption: Although cereal legume-based diets in India are adequate in iron
content to meet the RDA, the iron absorption is low. Presence of fibre, phytates and tannins
interfere with iron absorption. Additionally lower intake of those factors such as ascorbic
acid, haem iron and proteins, that aid in iron absorption further compromise iron uptake by
the body.
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ii. Abnormal blood loss: This may happen due to several reasons such as- occult blood loss from
gastrointestinal tract and is common among those with cow’s milk sensitivity; gastritis due to
stomach infection from helicobacter pylori; chronic use of drugs aspirin; bleeding ulcers or
tumours; and hook worm infestation.
iii. Increased demands: During certain physiological conditions associated with growth and
reproduction, iron demands are higher. When concurrently iron intakes are low, it results in
iron insufficiency.
Effects of iron deficiency
Hypochromic, microcytic anaemia occurs mainly due to dietary deficiency of iron. It impacts the
physical work capacity, behaviour, cognitive function, body temperature regulation, immunity. Iron
deficiency passes through milder sub clinical stages before frank symptoms anaemia occurs. At first
there is depletion of iron stores as measured by a decrease in serum ferritin which reflects the ferritin
supply (iron stores) in the body, without loss of essential iron compounds and without any evidence of
anaemia. In the second stage biochemical changes occur that reflect the lack of iron sufficient for the
normal production of haemoglobin and other iron compounds. This is indicated by a decrease in
transferrin saturation levels and an increase in erythrocyte protoporphyrin and is called iron deficiency
without anaemia. And finally, if left untreated, iron deficiency anaemia occurs.
Symptoms of anaemia
As iron stores are depleted, iron deficiency anaemia develops. Patients with all types of anaemia will
often present with similar symptoms regardless of the cause. Low RBCs decrease the oxygen-carrying
capacity of the blood, producing generalized symptoms. First of all, it is characterised with depressed
haemoglobin production and a change in the mean corpuscular volume of the RBC to produce a
microcytic hypochromic anaemia. Anaemias that develop rapidly, such as in acute bleeding, will be
more symptomatic than anaemias that progress slowly over months to years. Following clinical
features are observed -
The heart must increase the rate of blood flow to the body to compensate for anaemia. This may
precipitate palpitations, shortness of breath, and throbbing headaches.
Syncope occurs with severe anaemia due to decreased oxygenation of the brain in the upright
position.
Pallor and weakness: skin and mucous membranes may be pale and the heart rate may be increased
Changes in the nails and tongue: Nails take on a spoon shape when the iron-deficient state is severe.
Iron deficiency anaemia may cause brittle “spoon” nails (koilonychia), blue-tinted sclera, and a
painful tongue (glossitis).
Reproduction: This type of anaemia is associated with a higher risk of pre-term delivery, of low birth
weight and perinatal death.
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Immunity may be impaired due to the lack of iron needed by white blood cells and the enzymes used
in host defence.
Pica is another typical manifestation of iron deficiency whereby the appetite is altered and patients
crave for non-nutritional substances to eat such as ice, starch, or clay. However, clay inhibits
absorption of iron and may perpetuate the condition.
Symptoms of Anaemia
Symptoms
Dyspnoea with exertion
Dizziness
Light headedness
Throbbing headaches
Tinnitus
Palpitations
Syncope
Fatigue
Disrupted sleep patterns
Decreased libido
Mood disturbances
Difficulty concentrating
Assessment of iron deficiency
Assessment of iron deficiency includes the determination of levels of tissue and serum ferritin,
transferrin, red cell number and size (mean corpuscular volume). The final stage of iron deficiency
anaemia is reflected in haematocrit, and haemoglobin levels.
Serum ferritin: is a good indicator of iron stores. Serum ferritin levels <12µg/L are strongly
suggestive of iron depletion.
Transferrin saturation reflects adequacy of iron transport to the tissue and is determined by dividing
serum iron concentration / transferrin concentration. Measured by total iron binding capacity. When
transferrin saturation is low (<16%) it is often associated with iron deficiency. Very high value (>50%
for women) is associated with hereditary hemochromatosis. Infections and inflammatory conditions
often depress serum iron levels resulting in lowering of serum transferrin saturation value.
Haemoglobin (Hb): Abnormally low Hb is the most common test for screening iron deficiency (table
4). Low Hb may result from infection and even mild inflammatory disease. Racial differences may
also occur.
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TABLE 4: CUT-OFF POINTS OF HB VALUES FOR DIAGNOSIS OF ANAEMIA FOR

INDIANS
Category Hb (g/dl)
Adult men <13
Adult women <12
Pregnant women <11
Lactating women <12
Children <6 years <11
Older children <12
Haematocrit: Haematocrit is the percentage of red blood cells in a person’s blood. Low red blood
cell levels indicate conditions such as anaemia. High red blood cell levels could signal polycythaemia,
which can increase a person’s chance of developing a blood clot. The haematocrit is a ratio of the
packed cells to total volume. Example: If the column of packed red cells measures 20 mm and the
whole blood column measures 50 mm, the haematocrit is 20/50 = 0.4 or (0.4 × 100%) = 40%. Red
blood cells (RBCs) typically make up roughly 37% to 49% of the volume of blood.
Prevention and treatment of iron deficiency
Prevention: According to WHO actions to prevent anaemia are complementary, with their relative
importance depending on local conditions and specific needs. When implementing policy actions, a
package of interventions should be considered. These include:
 Promoting practice of proper sanitation, hygiene, food safety, anthelminthic therapy for worm
disinfestation. Availability/accessibility to improved sources of water and toilets.
 Monitoring and evaluation of antenatal and postnatal care, early registration of pregnancy,
assessment of anaemia status, diet assessment and advise, iron folic acid supplementation,
nutritional support.
 Improving dietary diversification and bioavailability of iron, and promoting iron rich food
consumption
 Food fortification of staple foods with iron, folic acid and vitamins or point of use, bio
fortification.
 Socio economic support and development- social safety nets, cash transfers to improve food
security, education and women’s empowerment.
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 Agricultural intervention to promote increased availability of food grains and iron rich foods.
 Improving knowledge and dietary practices through behaviour change communication.
Treatment: The treatment of iron deficiency anaemia is a pharmacologic activity and involves giving
large doses of iron, usually equivalent to 60 mg of elemental iron or 300 mg of ferrous sulphate, once
or twice a day. It is usually given with meals to minimize gastrointestinal side effects and maximize
uptake. Fortunately, the more severe the anaemia, the greater will be the percentage of iron absorbed.
Iron supplementation is usually continued for 2 to 3 months to normalize haemoglobin levels and iron
stores. These should be monitored until satisfactory values are obtained.
Toxicity
Excessive intake can result in toxicity. Primary overload is due to hereditary hemochromatosis.
Secondary iron overload from excessive oral intake or from repeated transfusions for severe anaemia
also occurs. Among children it is usually seen when they accidently ingest iron pills or iron-vitamin
supplements.
Effect of iron toxicity: Iron binding proteins prevent free iron to circulate in the body. When excess
iron reaches the system exceeding the capacity of the iron binding proteins free iron interacts with
cellular components. Free iron is able to catalyse the Fenton reaction which converts the superoxide
radical O2• and hydrogen peroxide to the hydroxyl radical OH• which is a potent reactive oxygen
species capable of causing free radical damage to cell membranes, proteins and DNA.
Severe iron poisoning is characterized by damage to the intestine with bloody diarrhoea, vomiting,
and sometimes liver failure. Systemic effects include haemorrhage, metabolic acidosis, and shock.
Lethal doses are in excess of 200 to 250 mg/kg. The toxicity of iron depends upon the form in which
it is present. Ferrous ions are absorbed more efficiently than ferric ions.
Treatment: Effective treatment includes induced emesis (vomiting), food and electrolyte treatment to
prevent shock, and the use of iron-chelating agents to bind the iron. This treatment has substantially
decreased the mortality from about 50% in 1950 to less than a few percent in recent years.
7.5. IODINE
Iodine is widely and unevenly distributed in the earth’s environment. Most Iodide is found in sea
water (50 µg/L) as iodide, upon oxidization it converts to iodine and volatilizes into air and is returned
to the earth’s surface in rain water. Iodine cycle is slow and incomplete in many regions. Flooding
results in leaching. This is the case in mountainous areas, which have Iodine deficient soils. Such
depleted soils will provide food deficient in Iodine. Foods grown in Iodine sufficient soils will contain
1 mg/kg while same food grown in deficient soils may have only 10 µg/kg. Iodine is an essential
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constituent of the thyroid hormones, thyroxine (T4) and triiodothyronine (T3), which have key roles
in development and growth. Thyroid hormones stimulate enzyme synthesis, oxygen consumption and
basal metabolic rate and, thereby, affect the heart rate, respiratory rate, mobilization and metabolism
of carbohydrates, lipogenesis. About 90% of the iodine requirement is met through food, while the
rest is obtained through drinking water. Daily intake of 10 g of iodized salt having iodine at a
minimum level of 15 ppm provides about 150 µg per day, in addition to iodine present in foods
consumed. Iodine deficiency disorders (IDD) are an important public health problem in India and
globally.
Prevalence:
Goitre has been described as early as 500 BC as ‘Galganda’ and appears in works of ancient Indian
scholars Sushruta and Charaka. Goitre has been reported in foothills of Himalaya, Aravalli, Vindhyas
and in hilly areas of other states. Classical endemic belt of IDD extends from the State of Jammu and
Kashmir in the North, through parts of Punjab, Haryana, Himachal Pradesh, Uttarakhand, Uttar
Pradesh, Northern part of Bihar, and West Bengal to North-Eastern states.
Globally, India has the largest number of children born vulnerable to iodine-deficiency. An estimated
350 million people do not consume adequately iodized salt and, therefore, are at risk for IDD. Of the
365 districts surveyed in India so far, 303 are IDD-endemic. However, repeat surveys in several areas
are showing consistent decline in prevalence of goitre. Prevalence of goitre ranged between 0.9 to
17.5% suggesting a wide variation among states. Currently, about 71% of households are consuming
salt with adequate levels of iodine. A well-defined strategy is required in order to reach the last 30%
of households that are likely to be least accessible and most socioeconomically disadvantaged.
Aetiology of goitre
Environmental factors are the most common cause of goitre, these are:
Low iodine content of soils used to grow food and feed crops and water are the main cause for dietary
iodine deficiency.
Goitrogens: Presence of active goitrogens such as several sulphur-containing compounds,

thiocyanate, iso-thiocyanate and goitrin inhibit transport by competing for uptake with iodide by the
body. Thiourea, thioamides and flavonoids interfere with thyroxine synthesis. Tobacco smoke also
contributes thiocyanate and other anti-thyroid compounds to the circulation. Excess iodine and lithium
interfere with utilization of thyroxine
Dietary sources of goitrogens: Goitrogens are found in common food stuffs especially some
vegetables of brassica family such as cabbage, turnips, brussels sprouts, rape seed, cauliflower,
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mustard. Sorghum, finger millet, groundnut also contain goitrogens. The most important of these
goitrogen-containing foods is cassava, which can be detoxified by soaking in water.
Effects of iodine deficiency
IDD constitute the single largest cause of preventable brain damage worldwide leading to learning
disabilities and psychomotor impairment. Children living in iodine-deficient areas on an average have
lower intelligence quotient (IQ), by as much as 13.5 IQ points as compared to children living in
iodine-sufficient areas. Symptoms differ depending on life stage at which deficiency occurs. Iodine
deficiency is defined by the World Health Organization (WHO) as a population median urinary iodine
concentration (UIC) that falls below 100 μg/L.
Clinical features of goitre: Iodine deficiency disorder (IDD) is a wide spectrum of disorders from
mild goitre to the most severe forms cretinism (Table 3).
Cretinism: Clinically is of two types depending on the stage in life cycle that it occurred.
Neurological cretinism exhibits predominant neurological syndrome with severe to profound mental
retardation, including defects of hearing and speech often deaf–mutism, squint, disorders of stance
and gait of varying degrees. This is seen generally in areas where there is environmental iodine
deficiency i.e., areas with iodine deficient soil and water.
Myxedematous cretinism: stunted growth with less severe mental retardation. Characteristic
symptoms are weakness, cold intolerance, mental and physical slowness, dry skin, sluggish bowel
movement, and hoarse voice. Results of the total serum thyroxine and free thyroxine index tests
usually will confirm the diagnosis.
Goitre: It is the mildest form of IDD - larger thyroid gland than normal range, from those only
detectable by touch (palpation) to very large goitres that can cause breathing problems. The
enlargement of the thyroid gland to produce goitre arises from stimulation of the thyroid cells by TSH
and, without the ability to increase hormone production owing to iodine deficiency, the gland
becomes hyperplastic.
Hypothyroidism: Hypothyroidism is a common condition where the thyroid doesn’t create and
release enough thyroid hormone into your bloodstream. Serum T4 levels will be low. This makes your
metabolism slow down. Also called underactive thyroid, hypothyroidism can make you feel tired,
gain weight and be unable to tolerate cold temperatures. The main treatment for hypothyroidism is
hormone replacement therapy.
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Table 3: Spectrum of iodine deficiency disorders
Stage of life cycle at which deficiency Prominent symptoms

occurred
Foetus Abortions
Still births
Congenital Anomalies
Increased Infant Mortality
Neurological Cretinism Deaf-mutism
Spastic diplegia
Squint
Myxedematous Cretinism
Dwarfism
Mental deficiency
Psychomotor defects
Neonate Neonatal Goitre
Neonatal Hypothyroidism
Child and Adolescent Goitre
Juvenile Hypothyroidism
Retarded physical development
Adult Goitre with its complications
Hypothyroidism
Impaired mental function
Assessment
To evaluate the severity of IDD in a region, the most widely accepted marker is the
prevalence of endemic goitre in school children while the iodine status of the population is
assessed by population’s urinary iodine concentration-
Classification of endemic goitre: According to the World Health Organization (WHO)

classification; Grade 0: no goitre is palpable or visible. Grade 1: palpable goitre, not visible
when neck is held in normal position. Grade 2: a clearly swollen neck (also visible in normal
position of the neck) that is consistent with a goitre on palpation.
Iodine urinary iodine concentration: The median urinary iodine concentration in the general
population should be within the range 100–199 µg/l. The median urinary iodine concentration
in the pregnant women population should be within the range 150–249 µg/l. The most recent
monitoring data (national or regional) should have been collected within the last five years.
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Prevention and treatment of IDD
Encouraged by the results of iodized salt supplementation experiment in Kangra valley of

Himachal Pradesh, Government of India (GOI), in the year 1962, launched the National
Goitre Control Programme (NGCP). Currently the problem of severe forms of Iodine
Deficiency Disease (IDD) (an environmental problem) has been considerably reduced after
the introduction of universal iodised salt. The process of iodization salt was started in a
phased manner in the country from April, 1986. In 1992, the NGCP was renamed the
National Iodine Deficiency Disorders Control Programme (NIDDCP).
Iodised salt: Fortification of salt with KIO3 or KIO2. Potassium iodate produces more stable
iodised salt. Levels of iodine in salt as potassium iodate (IO3) should be 25 ppm, 10 g of salt
should contribute the daily needs of 150 µg of iodine. Mild to moderate IDD can be controlled
by consuming iodised salt.
Iodised oil: Oil fortified with iodine is used to treat new cases of cretinism and myxoedema. Two
forms are available- i) Lipiodol for injection and ii) Oriodol for oral administration. A single dose of
iodised oil gives long term protection of from 1-2 years.
Testing for iodine in household salt samples
Self-reporting: Self-reported estimates are used to get a very rough estimate and require the
salt be tested for presence of iodine.
Rapid test kits for presence of iodine in salt: These kits allow for salt to be tested for presence
of iodine in a sample of salt within the household during the survey. This helps in decreasing
the bias of estimates based on self-reporting from household survey data and represents an
example of direct testing in household surveys.
Quantitative tests for iodine: The most recent WHO recommendation is to use quantitative
methods such as titration to quantify iodine content in salt samples gathered through
household surveys.
Toxicity
Adverse effects of Iodine supplementation have not been observed in India. A Tasmanian
study reported a few cases of “Thyrotoxicosis” due to very high intakes of Iodine.
Thyrotoxicosis is a condition that occurs due to excessive thyroid hormone resulting in
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hyperthyroidism. Signs and symptoms vary between people and may include irritability,
muscle weakness, sleeping problems, a fast heartbeat, heat intolerance, diarrhoea, enlargement of
the thyroid, and weight loss. This can be treated with antithyroid drugs.
7.6. ZINC
An Indian physician, Prasad and his co-workers established that zinc is an essential nutrient.
He observed that clinical syndrome of dwarfism and hypogonadism in Iranian boys was due
to a dietary deficiency of zinc. Zinc is found in choroid of eye and prostate glands, bones and
muscles. Zinc has diverse roles in the body, it is needed for cell division and growth, new
protein synthesis, male sex hormone synthesis, stabilization of bio-membranes by binding to
sulphydryl groups and forming mercaptides. It offers protection against free radical damage
that occurs due oxidative and nitrative inflammation It is important for strong immune system
and epithelial tissues. Has a role in retinol metabolism. Ca, Fe, Cu when in excess are found
to interfere with Zn absorption and vice versa. Soil factors are associated with zinc deficiency
in crops and humans. Maize is the most susceptible cereal crop, but wheat grown on zinc
deficient soils are also highly prone to Zn deficiency. Zinc fertilizers are used in the
prevention of Zn deficiency and in the biofortification of cereal grains.
Deficiency
With so many diverse functions (listed in the above paragraph) its deficiency is known to
have some serious consequences. Deficiency results in growth failure, hypogonadism,
hypogeusia (loss of taste), night blindness.
Moderate Zinc deficiency results in growth retardation, male hypogonadism, skin changes,
poor appetite, mental lethargy, abnormal dark adaptation, delayed wound healing.
Severe deficiency results in neuropsychiatric changes, dermal lesions, diarrhoea and
alopecia. In children, growth is compromised and there are recurrent infections.
Diarrhoea and zinc deficiency: The risk of zinc deficiency, is enhanced by diarrhoea which
is associated with variable but sometimes gross increases in zinc losses in the faeces. Thus,
proper management of diarrhoea is important in order to prevent and correct zinc deficiency
and involves the following steps:
Prevention: Prevent dehydration through the early administration of increased amounts of
appropriate fluids available in the home, and oral rehydration salt (ORS) solution, if on hand.
Recognize the signs of dehydration and take the child to a health-care provider for ORS or
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intravenous electrolyte solution, as well as familiarize themselves with other symptoms

requiring medical treatment (e.g., bloody diarrhoea).
Continue feeding (or increase breastfeeding) during, and increase all feeding after the
episode.
Zinc supplementation: Provide infants with 20 mg per day of zinc supplementation for 10–14
days (10 mg per day for infants under six months old).
Zinc toxicity
It is relatively non-toxic and is not a common occurrence. In some instances, it has occurred
as a result of food contamination from galvanized food containers. Food or drink can pick up
significant quantities of zinc as it leaches from the container into the food especially if the
food or drink is slightly acidic and the storage is prolonged. Chronic excess zinc ingestion in
the range of 100 to 300 mg/day in the absence of adequate copper intake can also result in
toxicity.
Symptoms of acute toxicity of zinc alone include nausea, vomiting, epigastric pain,
abdominal cramps, and diarrhea. In severe cases the diarrhea can be bloody. Central nervous
system symptoms (lethargy, light-headedness, staggering gait, and difficulty with fine finger
movement) have been reported in individual consuming elemental zinc in large quantities.
Zinc toxicity may decrease HDL and cause immunosuppression.
Zinc toxicity due to copper deficiency result in symptoms that almost mimic those of copper
deficiency. These symptoms include low blood copper levels, anaemia, leukopenia, and
neutropenia. The use of a copper supplement will reverse the condition. This means adequate
copper intake protects against toxicity of moderate zinc overload.
7.7. FLOURIDE
It is an element known to provide hardness to teeth and bones, and which also inhibits tooth
decay. In excess, it is toxic. Fluoride is needed for maintenance of dental health and bone
structure. The function of fluoride appears to be in the crystalline structure of bones. Fluoride
forms calcium fluor-hydroxyapatite in teeth and bone. The incorporation of fluoride in these
tissues is proportional to its total intake. Food and water are main sources. Other rich sources
are tea, green leaves, sea food. Fluoride has been proven to protect teeth from decay and acid
produced due to bacteria when a person eats sugary foods. This acid erodes minerals from the
tooth’s surface, increasing the chance of developing cavities. Fluoride helps to rebuild and
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strengthen the tooth’s surface, or enamel. Water fluoridation is done in places where water
contains low fluoride content to prevents tooth decay. By keeping the tooth strong and solid, fluoride
stops cavities from forming and can even rebuild the tooth’s surface.
Indian foods contain higher fluoride than those in Western countries. Dietary fluoride intake is in
range of 0.3-0.8 mg/d. Total fluoride intake [Diet + Water] is around 2.0-3.0 mg/d and higher in areas
where fluoride content of water is >1.0 ppm. Excess fluoride in water results in Fluorosis.
Aetiology of fluorosis
Where drinking water contains more than 1 ppm of fluorine. Chronic ingestion of higher
amounts leads to “fluorosis”. People whose staple is sorghum are susceptible to fluorosis due
to high levels of molybdenum in sorghum. Low calcium intakes and copper deficiency also
contribute.
Features of fluorosis
Intake 3–5 times the normal intake is mildly toxic. Tooth mottling occurs in mild toxicity and
chronic excess (10 mg/d) causes joint and bone abnormalities.
Mild forms of deficiency: The majority of cases are mild and do not permanently damage
teeth, and severe cases of fluorosis are not common. When it's mild, fluorosis is a painless
cosmetic condition. It can cause the appearance of the tooth enamel to change, usually
becoming stained with white "splotches" or "streaking” (mottled teeth). Severe fluorosis can
compromise dental health.
Dental fluorosis: affects the enamel. Due to increased fluoride uptake by the tooth; there is a
decreased calcification in teeth.
Skeletal fluorosis: This is characterised by muscular skeletal dysfunction, arthritis, fixed

flexion deformities resulting in restricted movement of joints, stiffness of spine.
Endemic Genu valgum: Genu valgum is commonly called "knock-knee. The cause of the
endemic genu valgum and other bone deformities and the high fluoride content in the urine is
due to high fluoride in drinking water, probably enhanced by deficient nutrition. Fluorosis per
se can cause genu valgum and rickets-like radiological features.
Fluorosis control measures
Defluoridation techniques can be broadly classified in to four categories-
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 Precipitation techniques
 Adsorption technique
 Ion- exchange technique- Anion/ Cation exchange resins
 Other techniques, which include electro chemical defluoridation and reverse osmosis
Precipitation techniques: Lime, alum, poly aluminium chloride, poly aluminium hydroxy
sulphate, brushite are some of the substances that are used. Nalgonda technique using lime
and alum is popular technique. The Nalgonda technique employs flocculation principle. Lime
and alum are coagulants used to flocculate fluoride ions in the water.
Adsorption techniques for defluorination of drinking water: This involves carbon-based,

biomolecules that are very effective in defluoridation, like bone charcoal, processed bone,
tricalcium phosphate, activated carbon, activated magnesia, tamarind gel, activated alumina,
burnt clay, Phylanthus Emblica (Indian Goosebry).
Prevention of fluorosis:
Guidelines for prevention of fluorosis are-
 Use of only deflouridated water

 Ensure nutrient adequacy by including a wide range of foods and increased intake of
vitamin C
 Identification of foods high in fluoride and excluding them
 Avoidance of pesticides rich in fluorides
 Parboiling of paddy in safe water
 Inclusion of tamarind in the diet
Toxicity
Fluorine is a cumulative poison. Lethal dose in man is 2.5-5.0 g which cause acute
symptoms. Acute fluoride poisoning result in abdominal pain, diarrhoea, vomiting, excessive
salivation, thirst, perspiration and painful spasms of limbs.
7.8. TOXICITY OF OTHER MINERALS
Potassium
Consumption of high doses of potassium chloride can cause cardiac arrest especially if the
potassium is rapidly absorbable variety, pharmaceutical preparations of potassium chloride
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are designed to release potassium slowly. An excessive intake of potassium from food can
also cause gastrointestinal symptoms characterized by abdominal pain, nausea and vomiting.
This can happen if large quantities of potassium rich foods such as, apples or bananas are
consumed too rapidly. Hyperkalaemia can occur in chronic renal failure where the capacity of
the kidney to excrete potassium may be impaired, in which case it may be dietary restriction
of potassium is recommended.
Heavy metals
Lead, cadmium and mercury are heavy metals naturally present in the environment but also
as a consequence of pollution (e.g., from lead-containing paint, batteries, plumbing, industrial
emissions and leaded petrol). They are present at low concentrations in most foods, with
environmental sources being the main routes of contamination. Lead, cadmium and mercury
have no known beneficial biological effects and long-term (chronic) exposure can be
harmful.
Lead: Lead (Pb) absorption may constitute a serious risk to public health. It is a cumulative
poison, which may cause reduced cognitive development and intellectual performance in
children and increased blood pressure and cardiovascular diseases in adults. Childhood lead
poisoning usually occurs through the inadvertent consumption of lead. The water supply can
acquire lead from lead plumbing particularly in soft water areas where the pH of the water is
low, thus allowing the lead to dissolve in the water. In old houses, lead can still leach into the
water supply. Lead was also used for the capsules on bottles of wine and crystals of lead
tartrate sometimes form on the cork. Lead capsules are now being replaced with plastic
capsules. Besides having adverse effects on the nervous system, lead is a bone seeking
mineral and accumulates in bones and teeth.
Lead also interferes with the synthesis of porphyrins which are the building blocks of
haemoglobin, and chronic lead poisoning results in anaemia. Tolerable daily intake of 0.21
mg/d.
Cadmium: Cadmium is mainly used for electroplating, galvanization processes and in

batteries. Cadmium is a cumulative contaminant, which accumulates in the kidney causing
damage that eventually results in high blood pressure and an increased risk of related
disorders such as stroke; cadmium may also increase risk of cancer. In areas of Japan and
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China where rice is grown on soils contaminated by mining wastes results in a cadmium
toxicity disorder, ‘itai-itai’ (ouch-ouch) disease which is a crippling condition, characterized
by pain in the back and joints, osteomalacia, bone fractures, and occasional renal failure. The
effects of cadmium toxicity appear to be more severe in populations with poor intakes of iron,
calcium and zinc. Tolerable daily intake of 0.06 mg/day
Mercury: Mercury compounds are neurotoxins, which may induce alterations in the normal
development of the brain in infants and at higher levels may induce neurological changes in
adults. Organic forms, such as methyl mercury, can accumulate in the marine food chain and
cause poisoning in people who consume contaminated fish. It is very toxic with as little as
100 mg causing poisoning and 500 mg being fatal.
CHECK YOUR PROGRESS
1. Why is mineral toxicity becoming a problem nowadays?

2. What are two main causes of calcium deficiency in India?
3. What are effects of calcium deficiency?
4. How prevalent is anaemia in India?
5. What are the three broad causes of iron deficiency?
6. List the symptoms of iron deficiency?
7. Which is the most common test to diagnose anaemia?
8. Describe the iodine cycle.
9. What are causes of Iodine deficiency?
10. What is iodized salt?
11. What is the consequence of zinc deficiency?
12. Describe the Nalgonda technique for defluoridation of water.
13. Which heavy metals are common toxicants?
Fill in the blanks
1. ______ is called as one nutrient.

2. TUL of calcium for Indians is _____________.
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3. Presence of _______ and__________ adversely affect the absorption of iron.

4. ________________of elemental iron per day is given to treat anaemia.
5. Lethal doses of iron are in excess of __________ to____________mg/kg.
6. Larger thyroid gland than normal range is called as _____________.
7. ____________deficiency, is enhanced by diarrhoea
8. Drinking water contains more than _________ppm of fluorine results in fluorosis.
7.9. SUMMARY
Inadequate supply of minerals among a large portion of Indians is due to consumption of

predominantly cereal based diets. The mineral inadequacy is compounded because minerals
from plant sources are less well absorbed in the diet. Mineral interactions can also cause
deficiencies. Deficiencies of iron is a major public health problem and is the leading cause of
anaemia. Calcium and zinc deficiencies are problems that have received less attention but are
prevalent. Endemic goitre and fluorosis are seen frequently in several parts of the country.
Both anaemia and IDD result in impacting the physical and mental performance of
individuals. Calcium deficiency affects growth and bone health. Zinc deficiency
compromises the immune system among several other harmful effects. There are specific
ways by which they can be assessed. Potentially all minerals are poisonous when consumed
in excess. Risk of overconsumption of minerals has increased as several foods are now being
fortified with nutrients. The Tolerable Upper Limit (TUL) of intake for nutrients has been
therefore defined by the ICMR for Indians and can deter the problem of over dosing.
Accidental and environmental contamination can occur especially in the case of heavy
metals. Therefore, it is important for a public health professional to understand the
prevalence, effects of deficiencies and excesses and ways to mitigate these nutritional
problems.
7.10. GLOSSARY
Word Meaning
Estrogen or Any of various natural steroids (such as estradiol) that are formed
Oestrogen from androgen precursors, that are secreted chiefly by the ovaries,
placenta, adipose tissue, and testes, and that stimulate the
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development of female secondary sex characteristics and promote

the growth and maintenance of the female reproductive system.
Various synthetic or semisynthetic steroids (such as ethinyl
estradiol) that mimic the physiological effect of natural estrogens.
PTH Parathyroid hormone is a hormone of the parathyroid gland that

regulates the metabolism of calcium and phosphorus in the body.
Preeclampsia A serious condition developing in late pregnancy that is

characterized by a sudden rise in blood pressure, excessive weight
gain, generalized oedema, proteinuria, severe headache, and visual
disturbances.
Haem The nonprotein, iron-containing pigment, that is a component part

of haemoglobin, myoglobin, etc.
NFHS The National Family Health Survey (NFHS) is a large-scale, multi-

round survey conducted in a representative sample of households
throughout India. Five rounds of the survey have been conducted
since the first survey in 1992-93. The survey provides state and
national information for India on fertility, infant and child mortality,
Syncope Temporary loss of consciousness caused by a fall in blood pressure
Tinnitus Ringing or buzzing in the ears
Endemic Something is endemic when found in a particular geographic area,

region, or population
Hypogonadism Reduction or absence of hormone secretion or other physiological

activity of the gonads (testes or ovaries). Zinc deficiency causes
male hypogonadism.
Hyperkalemia Hyperkalemia is an elevated level of potassium (K +) in the blood.

2. Carolyn D. Berdanier, 1998, Advanced nutrition, CRC Press, Printed in the United
States of America
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3. Recommended dietary allowances and estimated average requirements nutrient

requirements for Indians – 2020, A Report of the Expert Group Indian Council of
Medical Research National Institute of Nutrition, ICMR, New Delhi.
4. Chandrakant S. Pandav, Kapil Yadav, Rahul Srivastava, Rijuta Pandav, and M.G.
Karmarkar, 2013, Iodine deficiency disorders (IDD) control in India Indian, J Med
Res., 2013 , 138(3): 418–433.
5. Chittari Venkata Harinarayan, Harinarayan Akhila and Edara Shanthisree, 2012,
Modern India and dietary calcium deficiency—half a century nutrition data—
retrospect–introspect and the road ahead Frontiers in Endocrinology, Volume 12,
www.frontiersin.org , Article 583654, p1-29.

1. Nowadays individuals may be increasingly relying on pharmaceutical nutrient
supplements. This may lead to overconsumption of minerals which may be toxic or create
unhealthy interactions with other minerals, e.g., too much calcium can hinder absorption
of zinc and iron.
2.
i) milk intake is low,
ii) most dietary calcium comes from cereals which are moderate sources and calcium
absorption is low from this source
3. Inadequate bone calcification and growth in children (rickets) and weak porous bones in
adults (osteoporosis).
a. Increased frequency of osteoporotic fractures with age.
b. Decrease rate of skeletal accretion prevents attainment of genetically
determined maximal peak bone mass.
c. May also play a role in etiology of – Hypertension, Preeclampsia and Colon
cancer
d. Should blood calcium levels fall acutely, calcium tetany will result, and unless
calcium is provided quickly by the intravenous route, death will ensue.
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4. Anaemia is the most prevalent nutritional disorder worldwide and in India.

According to NFHS round 5 statistics per cent prevalence of anaemia in among Indians is
Urban Rural
Children age 6-59 months 64.2 68.3
Non-pregnant women age 15-49 years 54.1 58.7
Pregnant women age 15-49 years 45.7 54.3
All women age 15-19 years 56.5 60.2
Men age 15-49 years 20.4 27.4
Men age 15-19 years (Hb<13.0 g/dl) 25.0 33.9
5. Three broad causes of iron deficiency are:

i. Poor iron absorption: Presence of fibre, phytates and tannins interfere with iron
absorption. Lower intake ascorbic acid, haem iron and proteins, further compromise
iron uptake by the body.
ii. Abnormal blood loss: due to cow’s milk sensitivity; gastritis due to stomach infection
from helicobacterpylori; chronic use of drugs aspirin; bleeding ulcers or tumours; and
hook worm infestation.
iii. Increased demands: Iron demands are higher in growth and reproduction.
6. Symptoms of anaemia are listed below-

Dyspnoea with exertion, Dizziness, Light headedness, Throbbing headaches, Tinnitus
Palpitations, Syncope, Fatigue, Disrupted sleep patterns, Decreased libido, Mood
disturbances, Difficulty concentrating
7. Haemoglobin levels are tested to assess iron status. Abnormally low Hb is the most
common test for screening iron deficiency.
8. Iodine is widely and unevenly distributed in the earth’s environment. Most Iodide is
found in sea water (50 µg/L) as iodide, upon oxidization it converts to iodine and
volatilizes into air and is returned to the earth’s surface in rain water.
9. Environmental factors are the most common cause of goitre, these are:
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Low iodine content of soils used to grow food and feed crops and water are the main cause
for dietary iodine deficiency.
Presence of active goitrogens such as several sulphur-containing compounds, thiocyanate,
iso-thiocyanate and goitrin inhibit transport by competing for uptake with iodide by the body.
Thiourea, thioamides and flavonoids interfere with thyroxine synthesis. Tobacco smoke also
contributes thiocyanate and other anti-thyroid compounds to the circulation. Excess iodine
and lithium interfere with utilization of thyroxine.
10. Iodised salt is fortification of salt with KIO3 or KIO2 Levels of iodine in salt as
potassium iodate (IO3) should be 25 ppm, 10 g of salt should contribute the daily needs
of 150 µg of iodine. Mild to moderate IDD can be controlled by consuming iodised salt.
11. Deficiency results in growth failure, hypogonadism, hypogeusia (loss of taste), and night
blindness. Moderate Zinc deficiency results in growth retardation, male hypogonadism,
skin changes, and poor appetite, mental lethargy, abnormal dark adaptation, delayed
wound healing. Severe deficiency results in neuropsychiatric changes, dermal lesions,
diarrhoea and alopecia. In children, growth is compromised and there are recurrent
infections.
12. Nalgonda technique involves using lime and alum. The Nalgonda technique employs
flocculation principle.
13. Lead, cadmium and mercury are heavy metals naturally present in the environment but
also as a consequence of pollution (e.g., from lead-containing paint, batteries, plumbing,
industrial emissions and leaded petrol). They are present at low concentrations in most
foods, with environmental sources being the main routes of contamination.
Fill in the blanks
1. Iron is called as one nutrient.
2. TUL of calcium for Indians is 2500mg/d__.
3. Presence of tannins and phytates (fibre, carbonate, phosphate) adversely affect the
absorption of iron.
4. 60 mg of elemental iron per day is given to treat anaemia.
5. Lethal doses of iron are in excess of 200 to 250 mg/kg.
6. Larger thyroid gland than normal range is called as goitre.
7. Zinc deficiency, is enhanced by diarrhoea
8. Drinking water contains more than 1 ppm of fluorine results in fluorosis.
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UNIT-8: MAJOR NUTRITIONAL PROBLEMS PREVALENT IN INDIA AND
PROGRAMMES TO COMBAT THEM
STRUCTURE
8.1. OBJECTIVES
8.2. INTRODUCTION
8.3. MAJOR NUTRITION PROBLEMS OF INDIA
8.4. POLICIES TO COMBAT NUTRITIONAL DISORDERS IN INDIA
8.5. MAJOR NUTRITION PROGRAMS
8.6. SUMMARY
8.7. GLOSSARY
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8.1. OBJECTIVES

• Understand the types and extent of nutritional problems of public health significance
• Understand the national programs to combat the major nutritional problems
8.2. INTRODUCTION
Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy

and/or nutrients. The condition encompasses both undernutrition and overweight and obesity.
Food intake and feeding behaviours in children are determined by the way a family eats and
their socio-economic backgrounds. Nutritional adequacies are a reflection of access to
adequate quantities of nutritious foods like fresh fruits and vegetables, legumes, nuts, meat
and milk. Lack of knowledge, about appropriate foods and feeding practices for the child’s
age and inadequate awareness and or means for proper caring and health-seeking behaviours
are other causative factors. The global burden of malnutrition is unacceptably high, with
nearly half of all deaths in children under five years linked to poor nutrition. Stunting in early
life can have long-term effects on health, physical and cognitive development, learning and
earning potential, thereby placing an immense human and economic toll at the individual,
household, community and national level. A global review on child stunting and economic
outcomes revealed a 1 cm increase in height was associated with a 4% increase in wages for
men and a 6% increase in wages for women. Investing in the reduction of child malnutrition
is paramount for human and economic development. Conversely, the nutrition transition has
accompanied a rise in the prevalence of overweight and obesity in India. Thus, to overcome
the major nutritional problems both due to deficiencies and excesses there are several
programs operational in the country. The government of India has strongly committed to
achieving the 2030 Sustainable Development Goals (SDGs). If undernutrition is not
effectively reduced, the country will not meet its SDG targets for maternal and child
mortality reduction. In addition, if overweight and obesity are not aggressively addressed, the
burden of non-communicable disease will compromise development of India and reduce its
contribution to global health and economic progress.
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8.3. MAJOR NUTRITION PROBLEMS OF INDIA

The major nutrition problems of India can be classified as follows and also indicated in fig.-1:
Nutritional problems due to under-nutrition
 Protein Energy Malnutrition (PEM)
 Micronutrient deficiencies
 Anaemia and iron deficiency
 Iodine deficiency disorders (IDD)
 Vitamin A deficiency (VAD)
Nutritional problems due to overnutrition
 Overweight and obesity
Fig-1: The burden of malnutrition among children and adults in India (in millions)
Source: Comprehensive National Nutrition Survey (CNNS) National Report. New Delhi.
Protein Energy Malnutrition (PEM)

Protein Energy Malnutrition is the most widespread form of malnutrition among pre-school
children of our country. A majority of them suffer from varying grades of malnutrition.
Surveys conducted between 1975 and 1990 indicated that the percentage of normal children
(for both the sexes pooled) has increased from 5.9% to 9.9% while the moderate form of
malnutrition declined from 47.5% to 43.8%.
As per the National family health survey (NFHS) -5 2019-2020 data there is a slight
improvement at an all-India level of protein energy nutrition. Stunting has declined from 38
to 36%, wasting from 21% to 19% and underweight from 36% to 32% at all India levels in
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NFHS-5 (2019-2020) compared to NFHS-4 (2015-16) respectively. In 2019-20 NFHS phase-II

States/UTs situation has improved in respect of child nutrition but the change is not significant as
drastic changes in respect of these indicators are unlikely in a short span period.
As per the Comprehensive National Nutrition Survey (CNNS) India (2016–18) stunting,
wasting and underweight among children were taken as measures of assessing PEM (fig.-2).
These conditions often occur together. Together, these reflect chronic or recurrent
undernutrition, usually associated with poverty, poor maternal health and nutrition, frequent
illness and/or inappropriate feeding and care in early life. These prevent children from
reaching their physical and cognitive potential. Under-fives are considered the most
vulnerable and prevalence is highest in this age group. The three indicators of malnutrition-
stunting (low height-for-age), wasting (low weight-for-height) and underweight (low weight-
for-age)- show an overall improvement compared to earlier surveys.
Fig-2: Types of malnutrition and reference measures, India, CNNS 2016–18
Source: Comprehensive National Nutrition Survey (CNNS), National Report. New Delhi
As per the Comprehensive National Nutrition Survey (CNNS) India (2016–18) stunting, wasting and
underweight among children aged 0–4 years is as follows-
Stunting: 35% of Indian children aged 0–4 years were stunted. A number of the most populous states
including Bihar, Madhya Pradesh Rajasthan and Uttar Pradesh, and had a high (37–42%) stunting
prevalence. The lowest prevalence of stunting (16–21%) was found in Goa and Jammu and Kashmir.
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A higher prevalence of stunting in under-fives was found in rural areas (37%) compared to urban
areas (27%). Also, children in the poorest wealth quintile were more likely to be stunted (49%), as
compared to 19% in the richest quintile.
Wasting: Overall, 17% of Indian children age 0–4 years were wasted. High prevalence (
20%) states included Madhya Pradesh, West Bengal, Tamil Nadu and Jharkhand. The states
with the lowest prevalence of under-five wasting were Manipur, Mizoram and Uttarakhand
(6% each). As season of measure can have a significant effect on the status of acute
malnutrition in children under five, the comparisons across states and surveys need to account
for seasonal variation. A higher proportion of children aged under five years of age in the
poorest wealth quintile were wasted (21%) compared to those in the highest wealth quintile
(13%).
Under weight: Overall, 33% of Indian children aged 0–4 years were underweight. Many
states in the north-east of India, such as Mizoram, Sikkim, Manipur, Arunachal Pradesh and
Nagaland, had the lowest prevalence ( 16%) of underweight. The states with the highest
prevalence ( 39%) of underweight were Bihar, Chhattisgarh, Madhya Pradesh and
Jharkhand. Rural areas had higher prevalence of underweight in children under five (36%)
compared to urban areas (26%). Scheduled tribes had the highest prevalence of underweight
(42%) as compared to scheduled castes (36%), other backward classes (33%), and other
groups (27%). Similar to stunting, children under five from the poorest wealth quintile had a
prevalence of underweight more than twice that of the children from households in the richest
wealth quintile (48% vs. 19%).
Micronutrient deficiencies
Micronutrient deficiencies are an important cause of morbidity and mortality, especially in
infants and pre-school children. Even mild to moderate micronutrient deficiencies can lead to
impaired cognitive development, poor physical growth, increased morbidity and decreased
work productivity in adulthood. Micronutrients of public health importance in childhood and
adolescence generally include iron, vitamin A, iodine and zinc. More recently, folate, vitamin
B12 and vitamin D have received greater attention. Sporadic studies suggest a high
prevalence of these micronutrient deficiencies in India. However, due to limited information
about the national burden of these conditions national programmes and policies are currently
not in place. To fill in the gaps in data, the Comprehensive National Nutrition Survey
(CNNS) India 2016–18 which is the largest micronutrient survey ever was conducted. The
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CNNS was conducted in all 30 states of India using a multi-stage survey design covering rural
and urban households. The survey collected data from three target population groups: pre-schoolers
(0–4 years), school-age children (5–9 years) and adolescents (10–19 years). Infant and young child
feeding (IYCF) practices shape the nutritional status of children under two years of age and impact
child survival and health and development outcomes in the long term. For older children and
adolescents, dietary diversity reflects access to a variety of foods and nutrient adequacy of the diet.
Key findings of CNNS 2016–18 regarding dietary practices:
 Initiation of breastfeeding - Fifty-seven percent of children aged 0–24 months were
breastfed within one hour of birth.
 Exclusive breastfeeding - Fifty-eight percent of infants under age six months were
exclusively breastfed.
 Continued breastfeeding at age one year - Eighty-three percent of children aged 12 to
15 months continued breastfeeding at one year of age.
 Complementary feeding - Timely complementary feeding was initiated for 53% of
infants aged 6 to 8 months.
 Minimum dietary diversity, meal frequency and acceptable diet - While 42% of
children aged 6 to 23 months were fed the minimum number of times per day for their age,
21% were fed an adequately diverse diet and 6% received a minimum acceptable diet.
 Food consumption among school-age children and adolescents
- More than 85% consumed dark green leafy vegetables and pulses or beans at least
once per week.
- One-third consumed eggs, fish or chicken or meat at least once per week.
- 60% consumed milk or curd at least once per week.
Anaemia
Anaemia has debilitating effects on overall health, which is why the World Health
Organization characterises it as a serious public health concern. When prevalence is between
20%-40%, incidence is considered moderate. Anaemia continues to be a major public health
problem in the country. While iron deficiency is an important cause of anaemia and of
concern at certain points in the life cycle (pregnancy, infancy and adolescence), several other
factors also contribute to anaemia including deficiencies of vitamin A, folate, vitamin B12
and zinc, illnesses, helminths and parasitic infections. Genetic conditions such as sickle cell
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anaemia and other haemoglobinopathies are also significant contributors to anaemia in South
Asia.
As per the NFHS data anaemia among children and women continues to be a cause of
concern. The incidence of anaemia has worsened in under-5 children (from 58.6 to 67%),
women (53.1 to 57%) and men (22.7 to 25%) in all states of India in NFHS -4 (2015-16) to
NFHS -5 2019-20 respectively. The Indian States show variation- from 39.4% in Kerala to
79.7% in Gujarat- but barring Kerala, all States are in the “severe” category. More than half
of the children and women (including pregnant women) are anaemic in the many States/UTs
and all-India levels compared to NFHS4, in spite of the substantial increase in the
consumption of Iron-Folic acid (IFA) tablets by pregnant women for 180 days or more.
The key findings of the comprehensive nutrition survey 2016-2018 (fig.-3) was- Forty-one
percent of pre-schoolers, 24% of school-age children and 28% of adolescents were anaemic.
Anaemia was most prevalent among children under two years of age. Female adolescents had
a higher prevalence of anaemia (40%) compared to their male counterparts (18%). Anaemia
was a moderate or severe public health problem among pre-schoolers in 27 states, among
school-age children in 15 states, and among adolescents in 20 states. Thirty-two percent of
pre-schoolers, 17% of school-age children and 22% of adolescents had iron deficiency (low
serum ferritin). Female adolescents had a higher prevalence of iron deficiency (31%)
compared to male adolescents (12%). Children and adolescents in urban areas had a higher
prevalence of iron deficiency compared to their rural counterparts.
Fig-3: Severity of anaemia across the three age groups, India, CNNS 2016–18
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Iodine Deficiency Disorder
Iodine is an essential nutrient and is needed for the production of thyroid hormone. Iodine
deficiency disorders (IDD) can lead to enlargement of the thyroid, hypothyroidism and, in
severe cases, to mental retardation. Goitre is the most visible indication of iodine deficiency.
National salt iodization programme has substantially reduced the global burden of iodine
deficiency.
According to WHO/UNICEF/ICCIDD guidelines, mean urinary iodine concentration (UIC)
<_50 μg/l is used to classify suboptimal iodine intake at the population level. In the CNNS
2016-18 survey, children and adolescents had adequate levels of urinary iodine. The mean
UIC was 213 μg/L among pre-school children, 175 μg/L among school-age children and 173
μg/L among adolescents in all states, except Tamil Nadu where mean UIC was > 300 μg/L
for all three age groups, both children and adolescents had adequate urinary iodine status.
There are regional variations in prevalence of IDD. Prevalence of goitre ranged between 0.9
to 17.5% suggesting a wide variation among states.
As per the surveys conducted by the Directorate General of Health Services, Indian Council
of Medical Research, Health Institutions and the State Health Directorates, it has been found
that out of 414 districts surveyed in all the 29 States and 7 UTs, 337 districts are endemic i.e
where the occurrence of Iodine Deficiency Disorders (IDDs) is more than 5%.
Vitamin ‘A’ Deficiency

Vitamin A is an essential micronutrient that is particularly important for immune function.
Vitamin A is critical during periods of rapid growth and inadequate intake can lead to
deficiency which, in severe cases, may cause visual impairment (night blindness) and
increase the risk of morbidity and mortality from common childhood infections.
Nutritional blindness which affects millions of children in India per year results mainly ‘from
the deficiency of Vitamin A. coupled with protein energy malnutrition. In its severest form, it
often results in loss of vision. Vitamin A deficiency is assessed on the basis of conjunctival
xerosis and bitot’s spots. A study of NNMB has indicated that, while there were no
manifestations of Vitamin A deficiency in infants, its prevalence increased with age. Further,
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a higher prevalence was seen in school age children in all the income groups. In the urban
areas it was the highest among slum children.
In the CNNS survey 2016, vitamin A deficiency (VAD) was measured by serum retinol
concentration. A cut-off of <20 μg/dL was used to define vitamin A deficiency among
children aged 1–9 years and adolescents aged 10–19 years. Among pre-school children aged
1–4 years, 18% were vitamin A deficient. Vitamin A deficiency prevalence increased with
age to 22% among school-age children aged 5–9 years and 16% among adolescents aged 10–
19 years (fig. 4).
Mothers’ education is associated with vitamin A deficiency prevalence was lowest among
adolescents whose mother had higher education. The prevalence of vitamin A deficiency
among children and adolescents varied widely by state. Among pre-schoolers, the low
prevalence was observed in Goa, Rajasthan, Himachal Pradesh, Sikkim and West Bengal and
high in Mizoram, Chhattisgarh and Jharkhand. According to the WHO guideline of
prevalence ≥ 20% is considered as severe public health problem and so vitamin A deficiency
was identified as a severe public health problem in 12 states among pre-school children and
in four states among adolescents.
Fig-4: Prevalence of vitamin A deficiency as a public health problem among children aged from
left to right- 1–4 years, 5-9 years, 10-19 years in India, CNNS 2016–18
Zinc deficiency
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Zinc deficiency is characterized by growth retardation, loss of appetite, and impaired immune
function. In more severe cases, zinc deficiency causes hair loss, diarrhoea, delayed sexual
maturation, impotence, hypogonadism in males, and eye and skin lesions. The zinc deficiency
has public health significance among children and adolescents.
In the CNNS 2016-18 survey, serum zinc concentration was used to diagnose zinc deficiency
among children and adolescent. Nearly one-fifth (19%) of pre-school children aged 1–4 years
and 17% of school-age children aged 5–9 years had zinc deficiency. Nearly one-third (32%)
of adolescents aged 10–19 years were zinc deficient. Zinc deficiency was more common in
rural areas and among poor compared to urban areas and richest households. More male
adolescents were zinc deficient, as compared to female adolescents. The prevalence of zinc
deficiency also varied across states, lowest in Nagaland and highest in Himachal Pradesh and
Gujarat.
Vitamin B12 and folate deficiency

Vitamin B12 and folate are necessary for the formation of healthy red blood cells, repair of
body cells and tissues, and for the synthesis of DNA. Vitamin B12 is also important for
maintaining normal nerve function. A deficiency in vitamin B12 or folate can lead to
macrocytic (enlarged red blood cell) anaemia. Vitamin B12 is found primarily in foods of
animal origin and risks for deficiency are therefore higher where access to these foods is
limited.
In the CNNS, 2016-18 survey vitamin B12 and folate levels were assessed by estimating
circulating levels of serum B12 and erythrocyte folate. According to WHO guidelines,
Vitamin B12 deficiency was defined as serum vitamin B12 < 203 pg/ml and folate deficiency
was defined as serum erythrocyte folate level < 151 ng/ml. Serum vitamin B12 concentration
and serum erythrocyte folate concentration to diagnose deficiency among children and
adolescents.
Vitamin B12 deficiency: Overall, 14% of pre-schoolchildren aged 1–4 years, 17% of school-
age children aged 5–9 years and 31% of adolescents aged 10–19 years had vitamin B12
deficiency. Among adolescents, differences in prevalence were observed by sex (35% for
boys vs. 27% for girls) and adolescent age, with 28% and 34% prevalence among adolescents
aged 10–14 and 15–19 years, respectively. Regional differences were observed. Lower
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prevalence was observed in Southern and Eastern states and higher in Western and northern
states.
Folate deficiency: About one-quarter (23%) of children aged 1–4 years had folate
deficiency. Prevalence was higher among children aged 5–9 years (28%) and adolescents
aged 10–19 years (37%). Additionally, a higher proportion of children aged 5–9 years and
adolescents aged 10–19 years from the wealthiest quintile were folate deficient, compared to
those from the poorest households: 30% vs. 21% among children aged 5–9 years and 43% vs.
28% among adolescents aged 10–19 years.
Vitamin D deficiency
Vitamin D is essential for bone health and adequate intake is required to prevent growth
faltering in children. The risk of vitamin D deficiency is high where there is low consumption
of foods rich in vitamin D and there is inadequate exposure to ultraviolet B (UVB) radiation
from sunlight. In the CNNS, 2016-18 survey vitamin D status was assessed by measuring
serum 25(OH)D concentration.
Vitamin D deficiency varied considerably across states. Vitamin D deficiency in Delhi,

Gujarat, Haryana, Jammu & Kashmir, Manipur, Punjab, Rajasthan and Uttarakhand, less than
10% of children were deficient in vitamin D in other states.
Fluorosis
Dental Fluorosis affects children and discolours and disfigures the teeth. The teeth could be
chalky white and may have white, yellow, brown or black spots or streaks on the enamel
surface. Discoloration is away from the gums and bilaterally symmetrical. Skeletal Fluorosis
affects the bones and major joints of the body like neck, back bone, shoulder, hip and knee
joints with severe pain, rigidity or stiffness in joints. In severe forms results in marked
disability. Non-Skeletal fluorosis is an earlier manifestation of fluorosis seen as gastro-
intestinal complaints etc. and may overlap with other diseases leading to misdiagnosis.
Fluorosis prevalence was reported in 230 districts of 19 States. As per present data from
Ministry of Drinking Water and Sanitation, there are 14,035 habitations (as on 1.4.2016)
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from 17 States which are yet to be provided with safe drinking water. The population at risk
based on population in habitations with high fluoride in drinking water is 115.3 lakh.
Overweight and obesity

Overweight and obesity is often associated with diet-related non-communicable diseases in
adult populations. Poor adolescent and/or maternal nutrition before and during pregnancy can
lead to increased risk of maternal anaemia and low birth weight. Undernutrition in utero and
early childhood can predispose individuals to become overweight and develop
noncommunicable diseases such as diabetes and heart disease in adulthood. Overweight in
mothers is also associated with overweight and obesity in their offspring. Rapid weight gain
following acute malnutrition early in life may predispose children to excess weight and the
associated risks in adulthood. Furthermore, the nutrition transition that has resulted from
globalization and economic growth has led to greater consumption of high-energy and
nutrient – poor processed foods and more sedentary lifestyles, contributes to the rapidly
growing overweight and obesity epidemic in India and globally.
In the CNNS, 2016-18 survey 2% of children under five were overweight or obese according
to weight for height. 5% of adolescents were overweight or obese (BMI-for-age >+1 SD), 2%
of adolescents had abdominal obesity (waist circumference-for-age >+1 SD).
According to the National Family Health Survey-5 (NFHS-5), released by the Ministry of
Health and Family Welfare, 3.4 percent of under 5 aged children were overweight (weight for
height). High risk waist-to-hip ratio of ≥0.85 was seen in 56.7% women and ≥0.90% in
47.7% men.
As per the NFHS-5 (2019-20) data one in every four Indians is now obese. Obesity among
women has increased from 21 per cent in 2015-16 to 24 per cent in 2019-20. Among men, it
has risen to 23 per cent in 2019-20 from 19 per cent in 2015-16.
One of the key findings of NFHS-5 (2019-2020) was an increase in childhood obesity. Out of
22 states and union territories, 20 of them, including Gujarat, Maharashtra, and Ladakh, saw
a rise in obesity among children.
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In Gujarat, the percentage of overweight children under 5 years of age increased from 1.9 per
cent to 3.9 per cent, whereas, in Maharashtra, it increased from 1.9 per cent in 2015-16 to 4.1
per cent in 2019-20. Ladakh saw a massive rise, from 4 per cent obese children under the age of five
(2015-16) to 13.4 per cent (2019-20).
Burden of Non-Communicable Disease (NCD)

India has been going through an epidemiological transition with an increase in the proportion
of disease burden attributable to non-communicable diseases (NCDs) as compared to that due
to infectious disease. NCDs account for 60% of all deaths in India. The major metabolic risk
factors for NCDs are elevated blood glucose, elevated total cholesterol and LDL levels and
raised blood pressure. For the first time in India, the CNNS provides a comprehensive set of
biomarkers of NCDs for children and adolescents at the national and state level, including: i)
fasting plasma glucose ii) glycosylated haemoglobin (HbA1c) iii) lipid profile: High total
cholesterol, low HDL, high LDL and high triglycerides iv) serum creatinine levels v) blood
pressure levels
- There is a growing risk of non-communicable diseases among children aged 5 to 9
years and adolescents aged 10–19 years in India.
- One in ten school-age children and adolescents were pre-diabetic with fasting plasma
glucose >100 mg/dl & 126 mg/dl or with glycosylated haemoglobin (HbA1c) between
5.7%–6.4%  One percent of school-age children and adolescents were diabetic with fasting
plasma glucose >126 mg/dl.
- Three percent of school-age children and 4% of adolescents had high total cholesterol
( 200 mg/dl) and high low-density lipoprotein (LDL) ( 130 mg/dl)
- One-quarter (26%) of school-age children and 28% of adolescents had low high-
density lipoprotein (HDL) (0.7 mg/dl for 5–12 years and > 1.0 mg/dl for  13 years)
- Five percent of adolescents were classified as having hypertension (systolic blood
pressure >139 mmHg or diastolic blood pressure >89 mmHg)
8.4. POLICIES TO COMBAT NUTRITIONAL DISORDERS IN INDIA
Dealing with undernutrition is obviously an urgent national priority in view of the

implications it has for overall health and development of children in India. Given that even
mild malnutrition is linked to a twofold increase in mortality, and to much lower productivity
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levels, these levels of undernutrition significantly compromise the health and productivity of
large sections of the Indian population. Physical retardation, increased vulnerability to
diseases through childhood and adulthood, impaired cognitive and motor development, and
limited educational accomplishments are major characteristics of the overall burden of ill
health caused, and reduced productivity perpetuates poverty.
Some milestones in tackling the malnutrition burden

- A global policy on food and nutrition after the 1974 World Food Conference placed
emphasis on food production as the solution to world hunger.
- In 1975 Integrated Child Development Services was launched.
- At the International Conference on Nutrition in 1992, WHO and FAO called all
developing countries to formulate a National Nutrition Policy (NNP). India, which had
already initiated actions in the early 1980s, adopted its NNP in 1993. In fact, India was one of
the first developing countries with an NNP in place.
- In the 1990s, various measures introduced to reduce malnutrition were equated with
hunger and poverty. Provision of nutrition supplements to children under 6 years of age
through the ICDS network remained the highest priority, despite the fact that mere provision
of food in the absence of active feeding and high incidence of gastroenteritis and diarrhoea
would have limited impact.
- A study carried out by the World Bank in 2009 outlined feasible and cost-
effectiveness interventions to alleviate global nutritional problems. These are listed below:
Promoting good nutritional practices
 Breastfeeding
 Complementary feeding
 Improved hygiene practices, including hand washing
Increasing intake of vitamins and minerals—provision of micronutrients for young children

and their mothers
 Periodic vitamin A supplements (excludes neonates)
 Therapeutic zinc supplements for diarrhoea management
 Multiple Micronutrient Powder
 Deworming drugs for children
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 Iron folic acid supplements for pregnant women

 Salt iodization (iodized oil if iodized salt not available)
 Iron fortification of staple food
Therapeutic feeding for malnourished children with special foods
 Prevention or treatment of moderate undernutrition
 Treatment of severe undernutrition with ready-to-use therapeutic foods (RUTF)
Fig-5: Salient features of malnutrition alleviation in India’s last ten five year plans
Source: POSHAN 2014

National Nutrition Policy, 1993
National Nutrition Policy was divided into direct strategies (short term) and indirect strategies
(long term). Direct strategies demanded focus on the following:
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 Ensuring proper nutrition of the target groups i.e. the vulnerable section of the society
(children, adolescent, pregnant and nursing women, etc.)
 Expanding the safety net for children (i.e. expanding the policy to rural slums along
with urban slums),
 Food fortification,
 Provisions for low-cost nutrition food, and
 Combating micro-nutrition deficiency in the vulnerable groups
 Indirect strategies demanded focus on the following:
 Food security,
 Improving the dietary pattern like providing nutritionally rich food at affordable cost,
 Improving purchasing power,
 Encouraging more of the small and medium enterprise to emerge,
 Prevention of food adulteration,
 Imparting nutrition education through social marketing, communication, etc.,
 Minimum wage administration,
 Equal remuneration for women,
 Monitoring of nutrition programs.
National Nutrition Mission or POSHAN Abhiyan, 2018

This is the Centre’s flagship program aimed at improving the nutritional outcomes for
children, pregnant and lactating women. It was launched by Prime Minister Narendra Modi in
March 2018. It is a multi-ministerial mission to ensure a malnutrition-free India. Its main
focus is on tackling the issue of malnutrition.
National Food Security Act, 2013

Enacted by the Parliament, this Act came into force in 2013. It aims to provide at least 5 kg
of food grains per month at a subsidized price to around 75% of the rural population and 50%
of the urban population. This Act also aims to provide nutritional support to pregnant women
and lactating mothers along with children aged 6 months to 14 years.
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National Nutrition Monitoring Bureau, 1972

Under the guidance of the Indian Council of Medical Research, the National Nutrition
Monitoring Bureau was established in the year 1972. It aimed to gather an informative
dynamic database on the diet and nutritional status of various communities. It also helped in
identifying the strengths and weaknesses of the intervention policies of the government. It
recommended corrective measures in the Central Nutritional Policies. The Bureau was,
however, shut down by the Union Ministry of Health in 2015. Now alternate data and
monitoring agencies are operating such as NFHS which is more aligned with the global
measures of nutritional and health indicators.
Child Development Services (ICDS),1975

It is a program initiated by the Central Government in India. It is more of a package of
integrated services. It provides food, preschool education, primary healthcare, immunization,
health check-up, and referral services to children under 6 years of age and their mothers. This
program sees implementation at the grass-root levels through Anganwadi workers.
8.5. MAJOR NUTRITION PROGRAMS
The major nutrition programs in India are described below and in Table-1.
National Vitamin A Prophylaxis Programme,1970
Objective: The programme was launched in 1970 by the ministry of health and family
welfare with one objective to reduce the disease and preventing blindness due to Vitamin A
deficiency. The main objective of this programme was to decrease the commonness of
Vitamin A deficiency from current 0.6% to ≤ 0.5%.
Salient features: It was started with seven states with severe problems later it was extended
country. Target group under this programme, children aged 6 months to 6 years were to be
administered a mega dose of vitamin A at 6 monthly intervals. To prioritize Vitamin A
administration, the programme was revised to give 5 mega doses at 6 months intervals to
children 9 months to 3 years of age. In view of adequate supplies of Vitamin A, the target
group has been revised to cover children 9 months- 5 years, since 2007.
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The main strategy was-

i. to provide health and nutrition education to encourage colostrum feeding, exclusive
breastfeeding for the first six months,
ii. the introduction of complementary feeding thereafter and adequate intake of Vitamin
A rich foods.
iii. Prophylactic Vitamin A as per the following dosage schedule:
 100000 IU at 9 months with measles immunisation
 200000 IU at 16-18 months, with DPT booster
 200000 IU every 6 months, up to the age of 5 years.
Thus, a total of 9 mega doses are to be given from 9 months of age up to 5 years. All children
those are suffered from xerophthalmia are to be treated at health facilities, given 1 dose of
Vitamin A if they have not received it in the previous month.
National Nutritional Anaemia Prophylaxis Programme
Objective: This programme was launched during 4th 5-year plan in 1970 by Ministry of
health and family welfare for the prevention of nutritional anaemia in mothers and children.
Salient features: The National Nutritional Anaemia Prophylaxis Programme is operated as

part of the RCH programme.
The target group is pregnant women, lactating mothers, acceptors of birth control and
adolescents. It has been expanded to include infants 6-12 months, school children 6-10 years
and adolescents 11-18 years of age, clinically found to be anaemic.
Main strategy: For infants and children, a liquid formulation having 20 mg elemental iron and
100 µgs folic acid per ml, is to be made available.
Dosage for various age groups are as follows:
 Children 6-59 months: 20 mg elemental iron + 100 ug folic acid for 100 days if the
child is clinically found to be anaemic.
 School going children; 6-10 years 30 mg elemental iron + 0.250 mg folic acid for 100
days.
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 Adolescents and adults, 100 mg elemental iron + 0.500 mg folic acid for 100 days,
girls are given greater priority in the programme.
 Pregnant women: one tablet of 100 mg elemental iron + 0.500 mg folic acid
prophylactically daily and if clinically anaemic, 2 such tablets to be given daily for 100 days.
 Lactating mothers and acceptors of family planning; one tablet containing 100 mg elemental
iron + 0.500 mg folic acid daily for 100 days.
The programme also aimed to include
 health and nutrition education to improve overall dietary intakes and encourage the use of
iron and folic acid rich foods as well as food items that help iron absorption.
National Iodine Deficiency Disorder Control Programme,1992

This program started as the National Goitre Control Programme (NGCP) in 1962. It was later
renamed to National Iodine Deficiency Disorders Control Programme (NIDDCP) in August
1992. This was to broaden the spectrum of iodine deficiency disorders like mental and
physical retardation, deaf-mutism, cretinism, stillbirths, etc.
Objective: The main aim of this programme was to minimize commonness of IDD ≤5% and
ensure 100% consumption of adequately iodized salt (15ppm) at the domestic level. Specific
objectives are:
• To check the Iodine Deficiency Disorders in the districts.
• Supply of iodized salt.
• Resurveys to assess the impact of iodized salt after every 5 years.
• Laboratory monitoring of iodized salt and urinary iodine excretion.
• Awareness programmes for health Education and Publicity.
Salient Features of the program are:

Nodal agency: National Iodine Deficiency Disorders Control Programme (NIDDCP)
Ministry of Health & Family Welfare is the nodal Ministry for implementation of National
Iodine Deficiency Disorders Control Programme (NIDDCP).
Strategy: Mandatory salt iodization; 150 micrograms of Iodine per 10 g of salt. Iodine is an
essential micronutrient required daily at 100-150 micrograms for normal human growth and
development. Deficiency of iodine can cause physical and mental retardation, abortions,
KSOU, Mysuru. 184

cretinism, stillbirth, deaf-mutism, squint and various types of goitre. The programme is being
implemented in all the States/UTs for entire population.
It is observed that after the years of implementation the Total Goitre Rate (TGR) in the entire country
is reduced significantly. Production of iodized salt also increased 65.00 lakh MT.
Supplementary Nutrition Programme

Supplementary Nutrition for Integrated child development services (ICDS) projects is
operational in rural areas, tribal areas and urban slums through Anganwadi Centres (AWC).
Objective of Supplementary Nutrition Programme is to improve health and nutritional status
of children below 6 years of age, pregnant and nursing mothers and adolescent girls of low-
income group.
Salient features: The scheme is implemented through the network of Anganwadi workers
under the ICDS and urban areas through the NGOs of the state with 300 feeding days in a
year supplement contains 500 calories of energy and 12-15 grams of protein per child per
day.
The Supplementary Nutrition Programme has two components:
- Morning snacks and hot cooked meals served daily at the AWC to all children
between 3-6 years attending preschool at AWC for 25 days in a month.
- Take Home Ration in the form of RTE Energy Dense as Micronutrient Fortified Food
and/or energy-dense food marked as ‘ICDS Food Supplement’. Food is given for children 6
months to 3 years and pregnant/lactating mothers.
Mid-Day Meal Scheme, 1995

It is a school meal program launched by the Government of India. It was formulated to ensure
better nutrition amongst the school-going children. It covered all the children of primary
schools run by the government or aided by the government. It allowed such children to
receive a fully prepared mid-day meal.
Nodal agency: This programme was launched by Ministry of Education in 1961. The scheme
has a long history especially in Tamil Nadu and Gujarat and has been expanded to all parts of
India after a landmark direction by the Supreme Court of India on November 28, 2001.
Objective: The aim of this scheme involves
- Provision of free to school-children on all working days.
- Protecting children from classroom hunger.
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- Increasing school enrolment and attendance; improved socialisation among children

belonging to all castes.
- Addressing malnutrition, and social empowerment through provision of employment
to women, reduce school drops outs, and improve the attendance.
Salient features: As per the current norms, the primary school children are provided with 30-
gram pulses, 75-gram vegetables and 7.5 grams vegetables.
Tithi Bhojan: Recently GOI included a new initiative called Tithi-Bhojan in the Mid-day
meal scheme to encourage local community participation in the programme. This concept
was first implemented in Gujarat from where the Indian Government has borrowed it to
replicate across the country. It seeks to involve the members of the community in the effort to
provide nutritious and healthy food to the children. The members of the community may
contribute/sponsor either utensils or food on special occasions/festivals. This is completely
voluntary, and the people in the community may contribute food items supplementary to the
midday already being provided like sweet, namkeen or sprouts. Greater participation and
involvement of religious and charitable institutions is also being promoted.
Akshaya Patra It was started in the year 2000 for feeding 1500 children in 5 schools of
Bangalore. Now it has a very large coverage. Private sectors also involved successfully in this
programme.
Table-1: A bird’s eye view of the National programs to combat undernutrition

Intervention Objecti Target Content Strategy Department/
ve population agency
Supplementar To Pre-school 500 kcal On spot Women and
y feeding prevent children energy & Take Child
PEM Pregnant & 12-15 g protein home Welfare
*
Lactating 600 kcal ICDS
woman energy &
16-20 g protein
Mid-day meal 450 kcal On spot Ministry of
programme for energy & Education
school children 12 g protein
-
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Vitamin A To Pre-school Massive Dose Six Ministry of

deficiency prevent children Vitamin A monthly Health &
Prophylaxis nutritio Family
programme nal Welfare
blindnes
s
National To Pregnant and 60 mg Iron 100 doses Ministry of
Nutritional prevent lactating 500 µg folic in last Health &
Anaemia and women, acid trimester Family
Prophylaxis control voluntary birth Welfare
Programme nutritio control 100 days
nal acceptors, 20 mg Iron in
anaemia adolescent girls, 100 µg folic calendar
Pre-school acid year
children
National To Population 150 Continuou Ministry of
Iodine prevent micrograms of s Health &
Deficiency iodine Iodine per 10 g Family
Disorder deficien of salt Welfare
Control cy
programme disorder
(NIDDCP) s
National programme for prevention and control of fluorosis
Fluorosis, a public health problem is caused by excess intake of fluoride through drinking
water/food products/industrial pollutants over a long period. It results in major health
disorders like dental fluorosis, skeletal fluorosis and non-skeletal fluorosis.
Programme coverage: The Government of India started the National Programme for
Prevention and Control of Fluorosis (NPPCF) as a new health initiative in the 11th Five Year
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Plan (2008-09) with the aim to prevent and control Fluorosis in the country. 100 districts of
17 States were covered during 11th Plan and additional 32 districts have been covered during
the 12th Five Year Plan.
Objectives: The NPPCF aims to prevent and control Fluorosis cases in the country. The
Objectives of the National Programme for Prevention & Control of Fluorosis are as follows:
- Assess and use the baseline survey data of fluorosis of Ministry of Drinking water &
Sanitation
- Comprehensive management of fluorosis in the selected areas;
- Capacity building for prevention, diagnosis and management of fluorosis cases.
Salient features: The strategy followed under the programme is surveillance of fluorosis in the
community; capacity building (Human Resource) in the form of training and manpower support;
establishment of diagnostic facilities in the district; health education for prevention and control of
fluorosis cases; management of fluorosis cases including supplementation, surgery and rehabilitation.
Programs to combat Obesity and Non-Communicable Disease

Untreated obesity act as a predisposing factor for non-communicable diseases such as
cardiovascular diseases (heart attack and stroke), diabetes, musculoskeletal disorders
(osteoarthritis), some cancers (including breast, ovarian, prostate, liver, gallbladder, kidney,
and colon). Investing in the prevention, management and treatment of obesity is a cost-
effective action for governments and health services. Investment can help achieve the 2025
targets set by the World Health Organization to halt the rise in obesity and to achieve a 25%
relative reduction in mortality from NCDs.
National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease
is in the National Monitoring Framework and Action Plan for Prevention and Control of Non-
Communicable Diseases (2013-2020), adopted by the Government of India, obesity has been
identified as an area of intervention.
National Programme for Prevention and Control of Cancer Diabetes, Cardiovascular

Diseases and Stroke (NPCDCS)
The Government of India in 2010 launched NPCDCS. The nodal agency is MOHFW, GOI.
Objective of the programme to increase awareness on risk factors, to set up infrastructure
(like NCD clinics, cardiac care units) and to carry out opportunistic screening at primary
health care levels.
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Salient features: The focus of the programme is on awareness generation for behaviour and
life-style changes, early diagnosis of persons with high levels of risk factors and their referral
to higher facilities for appropriate management. the programme activities up to district level have
been subsumed under National Health Mission (NHM).
Community-based interventions
CHETNA (Children Health Education through Nutrition and Health Awareness program),
was carried out in New Delhi and MARG (Medical Education for Children/Adolescents for
Realistic Prevention of Obesity and Diabetes and for Healthy Ageing), was carried out in 15
cities of North India covering nearly 700,000 children.
Objective: These interventions are aimed at generating awareness and providing a conducive
environment for children to follow a healthy lifestyle (balanced diet and increased physical
activity) and promote healthy food alternatives.
Salient features: Under these programs, children are given nutritional and physical activity
education with the help of lectures, leaflets, debates and skits. These comprehensive
programs initiated on a large scale for the first time in South Asia aimed to impart education
regarding healthy lifestyle not only to children, but also to teachers and parents. The MARG
program is the first large-scale community intervention project in South Asia, which focuses
100% on primary prevention of not only diabetes, but on non-communicable diseases in
general.
CHECK YOUR PROGRESS

1. List the major nutritional problems in India.
2. What is the extent of stunting, wasting and underweight in the under- five population
in India?
3. Which are the micronutrient deficiencies that are seen as public health problem in
India?
4. Write about the severity of anaemia in children.
5. What is the prevalence of vitamin A deficiency in India?
6. What are feasible and cost-effectiveness interventions to alleviate global nutritional
problems recommended by world bank?
7. Write the salient features of National Vitamin A Prophylaxis Programme.
KSOU, Mysuru. 189

8. Who is the target group of National Nutritional Anaemia Prophylaxis Programme?

9. What is the objective of the National Iodine Deficiency Disorders Control Programme
(NIDDCP)?
10. What are the salient features of supplementary nutrition program?
11. Which national program is aimed at tackling the problem of obesity in India?
Fill in the blanks

1. Comprehensive National Nutrition Survey 2016–18 was conducted in ____states of
India.
2. The incidence of anaemia has __________ in under-5 children in NFHS 5 round of
survey compared to NFHS 4.
3. With respect to IDD, it is labelled ___________, where the occurrence of Iodine
Deficiency Disorders (IDDs) is more than 5%.
4. In the CNNS survey 2016, vitamin A deficiency (VAD) was measured by
____________ concentration.
5. About _____________ of children aged 1–4 years had folate deficiency.
6. Fluorosis prevalence was reported in ___________districts of 19 States.
7. As per the NFHS-5 (2019-20) data one in every _________ Indians is now obese.
8. __________________________ as a new health initiative in the 11th Five Year Plan
(2008-09) with the aim to prevent and control Fluorosis in the country.
9. It is mandatory to have 150 micrograms of Iodine per 10 g of salt.
10. A new initiative called ______________ in the Mid-day meal scheme to encourage
local community participation in the programme.
8.6. SUMMARY
Assessment of the status of health and nutrition of a population is imperative to design
and implement sound public health policies and programmes. The various extensive national
health and nutrition surveys provide national-level information on different domains of
health. These provide vital information and statistics for the country, and the data generated
are used to identify the prevalence and risk factors for the diseases and health challenges
faced by a country. These include the National Family Health Survey, District Level
Household Survey, Annual Health Survey, National Nutrition Monitoring Bureau Survey,
Rapid Survey on Children and Comprehensive National Nutrition Survey. Assessment of the
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status of health and nutrition of a population is imperative to design and implement sound
public health policies and programmes.
Children, pregnant and lactating women are the most affected with a reduction in
cognitive and physical growth and prone to unhealthy which directly affect the productivity
of the country. Public health nutritional problems include- Protein energy undernutrition and
overweight. Micronutrients of public health importance in childhood and adolescence
generally include iron, vitamin A, iodine and zinc. More recently, folate, vitamin B12 and
vitamin D have received greater attention.
Hence, Government has devised several nutrition programmes like National
Nutritional Anaemia Prophylaxis Programme, National Goitre Control Programme, National,
Iodine Deficiency Disorders Control Programme, Midday Meal Programme, Supplementary
nutrition Programme, prevention of fluorosis. The activities in each program have been seen
and its impact assessed by various evaluation programs had a positive impact, although in
some parameters we are still lagging such as PEM and anaemia. Overnutrition is another
facet of malnutrition and is increasingly becoming a public health issue so there are some
measures taken to combat obesity and NCDs.
8.7. GLOSSARY
Quintile A quintile is a statistical value of a data set that represents 20% of
a given population, so the first quintile represents the lowest fifth
of the data (1% to 20%); the second quintile represents the second
fifth (21% to 40%) and so on.
Sickle cell anaemia Sickle cell disease is a group of inherited red blood cell disorders
that affect haemoglobin, the protein that carries oxygen through the
body. The condition affects more than 20 million people
worldwide. Normally, red blood cells are disc-shaped and flexible
enough to move easily through the blood vessels. If you have sickle
cell disease, your red blood cells are crescent- or “sickle”-shaped.
These cells do not bend or move easily and can block blood flow to
the rest of your body.
Helminths Helminth is a parasitic worm (such as a tapeworm, liver fluke,
ascarid, or leech); especially an intestinal worm.
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UVB radiation UVB radiation that is in the region of the ultraviolet spectrum
which extends from about 280 to 320 nm in wavelength and that is
primarily responsible for production of vitamin D under the skin.
Too much exposure can cause sunburn, aging of the skin, and the
development of skin cancer.
Neonate Neonate is a new born infant less than four weeks old.
Anganwadi Anganwadi is a type of rural child care centre in India. They were
started by the Indian government in 1975 as part of the Integrated
Child Development Services program to combat child hunger
and malnutrition.
Prophylaxis Prophylaxis is treatment or actions taken to prevent a disease. In
Greek, phylax means "guard", so prophylactic measures guard
against disease by taking action ahead of time.

1. Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF
and Population Council. 2019. Comprehensive National Nutrition Survey (CNNS)
National Report. New Delhi
2. Government Of India Ministry of Women & Child Development, 1993, National
Nutrition Policy, New Delhi
3. Vir, S., K. C. Sreenath, V. Bose, K. Chauhan, S. Mathur, and S. Menon. 2014.
National Policies and Strategic Plans to Tackle Undernutrition in India: A Review.
POSHAN Report No. 2. New Delhi: International Food Policy Research Institute.
4. Ministry of health and family welfare, Government of India, NFHS-5, 2019-21,
Compendium of fact sheet Key indicators, (Phase-II).

1. List the major nutritional problems in India.
The major nutrition problems of India can be classified as follows:
Nutritional problems due to under-nutrition
 Protein Energy Malnutrition (PEM)
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 Micronutrient deficiencies
 Anaemia and iron deficiency
 Iodine deficiency disorders (IDD)
 Vitamin A deficiency (VAD)
 Nutritional problems due to overnutrition, overweight and obesity
2. What is the extent of stunting, wasting and underweight in the under- five population
in India?
The percentage of under-five Indian children who are stunted is 35%, wasted is 17 % and
underweight is 33 %.
3. Which are the micronutrient deficiencies that are seen as public health problem in
India?
Micronutrients of public health importance in childhood and adolescence generally include
iron, vitamin A, iodine and zinc. More recently, folate, vitamin B12 and vitamin D have
received greater attention.
4. Write about the severity of anaemia in children.
Thirty-two percent of pre-schoolers, 17% of school-age children and 22% of adolescents had
iron deficiency (low serum ferritin). Female adolescents had a higher prevalence of iron
deficiency (31%) compared to male adolescents (12%). Children and adolescents in urban
areas had a higher prevalence of iron deficiency compared to their rural counterparts.
5. What is the prevalence of vitamin A deficiency in India?
Among pre-school children aged 1–4 years, 18% were vitamin A deficient. Vitamin A
deficiency prevalence increased with age to 22% among school-age children aged 5–9 years
and 16% among adolescents aged 10–19 years.
6. What are feasible and cost-effectiveness interventions to alleviate global nutritional
problems recommended by world bank?
a. Promoting good nutritional practices – such as Breastfeeding, complementary
feeding, Improved hygiene practices, including hand washing.
b. Increasing intake of vitamins and minerals—provision of micronutrients for young
children and their mothers, Periodic vitamin A supplements.
c. Therapeutic zinc supplements for diarrhoea management. Multiple Micronutrient
Powder, Deworming drugs for children, Iron folic acid supplements for pregnant women. Salt
iodization (iodized oil if iodized salt not available), Iron fortification of staple food.
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d. Therapeutic feeding for malnourished children with special foods. Prevention or

treatment of moderate undernutrition, Treatment of severe undernutrition with ready-to-use
therapeutic foods (RUTF).
7. Write the salient features of National Vitamin A Prophylaxis Programme.

It was started with seven states with severe problems later it was extended country. Target
group under this programme, children aged 6 months to 6 years were to be administered a
mega dose of vitamin A at 6 monthly intervals. To prioritize Vitamin A administration, the
programme was revised to give 5 mega doses at 6 months intervals to children 9 months to 3
years of age. In view of adequate supplies of Vitamin, A, the target group has been revised to
cover children 9 months- 5 years, since 2007.
8. Who is the target group of National Nutritional Anaemia Prophylaxis Programme?

The target group is pregnant women, lactating mothers, acceptors of birth control and
adolescents. It has been expanded to include infants 6-12 months, school children 6-10 years
and adolescents 11-18 years of age, clinically found to be anaemic.
9. What is the objective of the National Iodine Deficiency Disorders Control Programme
(NIDDCP)?
The main aim of this programme was to minimize commonness of IDD ≤5% and ensure
100% consumption of adequately iodized salt (15ppm) at the domestic level. Specific
objectives are:
• To check the Iodine Deficiency Disorders in the districts.
• Supply of iodized salt.
• Resurveys to assess the impact of iodized salt after every 5 years.
• Laboratory monitoring of iodized salt and urinary iodine excretion.
• Awareness programmes for health Education and Publicity.
10. What are the salient features of supplementary nutrition program?
Salient features: The scheme is implemented through the network of Anganwadi workers
under the ICDS and urban areas through the NGOs of the state with 300 feeding days in a
year supplement contains 500 calories of energy and 12-15 grams of protein per child per
day.
The Supplementary Nutrition Programme has two components:
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 Morning snacks and hot cooked meals served daily at the AWC to all children
between 3-6 years attending preschool at AWC for 25 days in a month.
 Take Home Ration in the form of RTE Energy Dense as Micronutrient Fortified Food
and/or energy-dense food marked as ‘ICDS Food Supplement’. Food is given for children 6
months to 3 years and pregnant/lactating mothers.
11. Which national program is aimed at tackling the problem of obesity in India?
National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease
is in the National Monitoring Framework and Action Plan for Prevention and Control of Non-
Communicable Diseases (2013-2020), adopted by the Government of India, obesity has been
identified as an area of intervention.
Fill in the blanks

1. Comprehensive National Nutrition Survey 2016–18 was conducted in 30 states of
India.
2. The incidence of anaemia has worsened in under-5 children in NFHS 5 round of
survey compared to NFHS 4.
3. With respect to IDD, it is labelled endemic, where the occurrence of Iodine
Deficiency Disorders (IDDs) is more than 5%.
4. In the CNNS survey 2016, vitamin A deficiency (VAD) was measured by serum
retinol concentration.
5. About one-quarter (23%) of children aged 1–4 years had folate deficiency.
6. Fluorosis prevalence was reported in 230 districts of 19 States.
7. As per the NFHS-5 (2019-20) data one in every four Indians is now obese.
8. National Programme for Prevention and Control of Fluorosis (NPPCF) as a new
health initiative in the 11th Five Year Plan (2008-09) with the aim to prevent and control
Fluorosis in the country.
9. It is mandatory to have 150 micrograms of Iodine per 10 g of salt.
10. A new initiative called Tithi-Bhojan in the Mid-day meal scheme to encourage local
community participation in the programme.
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BLOCK-III: NATIONAL AND GLOBAL AGENCIES AND POLICIES FOR

HEALTH AND DISEASE
Nutrition does not usually constitute a separate sector and so aspects of nutrition
policy appear under the policies of specific sectors, such as agricultural, food, health,
education, and social welfare. Policy affecting nutrition involves many government sectors.
In the process of national policy formulation, various ministries and departments of the
government (sectors) prepare programs for implementation during a specific plan period. In
developing countries, national policies are published for each sector in periodic national
development plans, usually every 5 years. Public policies essentially capture the intentions of
the government. Nutrition programmes are key turning points in implementation strategies
leading to food and nutrition improvement as a sound basis for socio-economic development.
In order to be effective and successful, they require a multi-pronged services with focused
planning along with policy support for effective implementation, reaching the unreachable
and empowering those at the grass roots.
Many schemes are currently in operation in India to reach to the vulnerable section of
the population in a targeted manner. Food for work scheme has been an important way of
assuring food for all. This scheme is being continuously streamlined to ensure that the aid
reaches the actual beneficiaries. Besides the governmental programs in health, nutrition and
empowerment, the NGOs play an important role. They are often more flexible and sensitive
to dynamics of the community. Importance of food safety has gained more importance in
modern society due to expansion of trade networks when food began to be shipped long
distances. Today, food safety is a global concern due to rapid growth in international trade of
food products and consumers are exposed to a greater variety of food products. Such trade
can introduce new or unfamiliar food safety risks, and the chain of responsibility has become
longer and more complex.
LEARNING OUTCOME:
 Understand about the national policies, acts and agencies involved directly or
indirectly to combat the major nutritional problems.
 Understand about the global and national programs related to nutrition.
 Understand about the nutrition surveillance system and status in India and concept of
food and nutrition security.
 Understand about the concept of food safety and quality and food laws.
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UNIT-9: NATIONAL AND GLOBAL NUTRITION POLICY
STRUCTURE
9.1. OBJECTIVES
9.2. INTRODUCTION
9.3. NATIONAL AND GLOBAL NUTRITION POLICY
9.4. NATIONAL NUTRITION POLICY
9.5. POSHAN ABHIYAN (NATIONAL NUTRITION MISSION)
9.6. SWACHH BHARAT ABHIYAAN
9.7. NATIONAL HEALTH POLICY 2017
9.8. NATIONAL FOOD SECURITY ACT 2013
9.9. THE INDIAN COUNCIL OF AGRICULTURAL RESEARCH (ICAR)
9.10. THE INDIAN COUNCIL OF MEDICAL RESEARCH (ICMR)
9.11. NATIONAL INSTITUTE OF NUTRITION (NIN)
9.12. NATIONAL NUTRITION MONITORING BUREAU (NNMB)
9.13. THE FOOD AND NUTRITION BOARD (FNB)
9.14. NUTRITION FOUNDATION OF INDIA (NFI)
9.15. SUMMARY
9.16. GLOSSARY
9.17. FURTHER READING
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9.1. OBJECTIVES

• Understand about the global and national policies related to nutrition.
• Understand about the national policies, acts and agencies involved directly or
indirectly to combat the major nutritional problems.
9.2. INTRODUCTION
Nutrition does not usually constitute a separate sector and so aspects of nutrition policy
appear under the policies of specific sectors, such as agricultural, food, health, education, and
social welfare. Policy affecting nutrition involves many government sectors. In the process of
national policy formulation, various ministries and departments of the government (sectors)
prepare programs for implementation during a specific plan period.
Those aspects of the national policy that are specifically designed to improve the state of
nutrition in a country are together defined as ‘nutrition policy’ or ‘food and nutrition policy.’
In developing countries, national policies are published for each sector in periodic national
development plans, usually every 5 years. Public policies essentially capture the intentions of
the government. Without a policy there can be no governance. To govern there must be a set
of guidelines. Policies provide those guidelines. Policies enable the public to measure the
achievements of the government.
Even after 75 years of independence, large numbers of malnourished people still
continue to exist in India. There have been number of policies, strategies, action plans, and
programs that have been conceptualized, resourced, and implemented during these decades to
combat undernutrition. These are constantly modified and changed to see what needs to be
done differently to ensure that the high levels of undernutrition be reduced rapidly.
Governments must be responsive to the dynamics of changing health and nutrition scenarios
in their countries. Global apex agencies often are in a position to formulate policies and set
goals for countries to achieve. In India the federal bodies have been very active and have
done a remarkable job of responding in a culturally appropriate manner.
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9.3. NATIONAL AND GLOBAL NUTRITION POLICY

The Indian policy response to the status of undernutrition in the country has unfolded against
the broader framework of the state of human development in the country and several
geopolitical, financial, and social factors that have influenced this. In any country, health
affects growth in their average expectancy and various socioeconomic indicators like Human
Development Index, Multidimensional Poverty Index, and Gross Domestic Product per capita
other way reducing the burden of disease.
Nutrition Related Global policies

Earlier, food production as the solution to world hunger was the main focus of global policy
on food and nutrition after the 1974 World Food Conference. Later in year 2000 the focus
shifted to include nutrition security as well as food security for which the United Nations
Millennium Development Goals (MDGs) were drawn. In 2015 SDGs were set up by
the United Nations General Assembly (UN-GA) and are intended to be achieved by 2030.
The focus of SDGs is comprehensive sustainability.
United Nations Millennium Development Goals (MDGs): The MDGs are drawn from the
actions and targets contained in the Millennium Declaration that was adopted by 189 nations-
and signed by 147 heads of state and governments during the UN Millennium Summit in
September 2000. The Millennium Development Goals (MDGs) are eight goals to be achieved
by 2015 that respond to the world’s main development challenges. The eight MDGs break
down into 18 quantifiable targets that are measured by 48 indicators.
 Goal 1: Eradicate extreme poverty and hunger
 Goal 2: Achieve universal primary education
 Goal 3: Promote gender equality and empower women
 Goal 4: Reduce child mortality
 Goal 5: Improve maternal health
 Goal 6: Combat HIV/AIDS, malaria and other diseases
 Goal 7: Ensure environmental sustainability
 Goal 8: Develop a Global Partnership for Development
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Sustainable Development Goals (SDGs): SDGs or Global Goals are a collection of 17

interlinked global goals designed to be a "shared blueprint for peace and prosperity for people
and the planet, now and into the future”. The SDGs were set up in 2015 by the United
Nations General Assembly (UN-GA) and are intended to be achieved by 2030. They are
included in a UN-GA Resolution called the 2030 Agenda or what is colloquially known
as Agenda 2030.The SDGs were developed in the Post-2015 Development Agenda as the
future global development framework to succeed the Millennium Development Goals which
were ended in 2015. The SDGs emphasize the interconnected environmental, social and
economic aspects of sustainable development, by putting sustainability at their centre. The 17
SDGs are:
Goal -1 No Poverty By 2030, eradicate extreme poverty for all people

everywhere.
Goal -2 Zero Hunger End hunger, achieve food security and improved
nutrition by 2030.
Goal -3 Good Health and Ensure healthy lives and promote well-being for all at all
Well-being ages by 2030.
Goal -4 Quality Education Ensure that all girls and boys complete free, equitable
and quality primary and secondary education by 2030.
Goal -5 Gender Equality To achieve gender equality and empower all women and
girls.
Goal -6 Clean Water and Ensure availability and sustainable management of water
Sanitation and sanitation for all by 2030.
Goal -7 Affordable and Clean Ensure access to affordable, reliable, sustainable and
Energy modern energy for all by 2030.
Goal -8 Decent Work and Promote sustained, inclusive and sustainable economic
Economic Growth growth.
Goal -9 Industry, Innovation Build resilient infrastructure, promote inclusive and
and Infrastructure sustainable industrialization and foster innovation by
2030.
Goal -10 Reduced Inequality Reduce inequality within and among countries by 2030.
Goal -11 Sustainable Cities Make cities and human settlements inclusive, safe,
and Communities resilient and sustainable.
Goal -12 Responsible Ensure sustainable consumption and production patterns.
Consumption and
Production
Goal -13 Climate Action Take urgent action to combat climate change and its
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impacts.
Goal -14 Life Below Water Conserve and sustainably use the oceans, seas and
marine resources for sustainable development.
Goal -15 Life on Land Protect, restore and promote sustainable use of terrestrial
ecosystems, combat desertification and halt biodiversity
loss.
Goal -16 Peace and Justice Promote peaceful and inclusive societies for sustainable
Strong Institutions development; provide access to justice for all.
Goal -17 Partnerships to Strengthen the means of implementation and revitalize
achieve the Goal the global partnership for sustainable development.
Nutrition-related policymaking in India

There has been a progressive prioritization to tackling undernutrition as a public health
challenge since the 1940s, with several specific policies, programs, and the Five-Year Plans
of the country committing to action. Previously, in the Fig-5 of Unit 8 the salient features of
malnutrition alleviation in India’s last ten five-year plans have been explained. Global and
Indian perspectives have been used to identify core issues that impact nutrition.
The data generated from community based national-level surveys with large sample size were
used as the basis for policies and action plans. The major surveys include the National Family
Health Surveys (NFHS), District Level Household Survey (DLHS), Annual Health Survey
(AHS), National Nutrition Monitoring Bureau (NNMB) Survey, Rapid Survey on Children
(RSoC) and Comprehensive National Nutrition Survey (CNNS).
Multisectoral action is a central theme in the modern macro-policy environment. Key areas
for convergence include the economic empowerment of women; food security; food and civil
supplies, including the Public Distribution System; and improving access to primary
healthcare. Policy formulation processes are systematic and policy revisions are active, so as
to address current issues and evidence that arise.
9.4. NATIONAL NUTRITION POLICY
National nutrition policy (NNP) was adopted by the government in 1993. It advocates a
comprehensive, integrated and intersectoral strategy for alleviating the multi-faceted problem
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of malnutrition and achieving the optimal state of nutrition for the people. Two types of
interventions are made to achieve the goals of the NNP.
A. Direct intervention: short term
 Nutrition intervention for vulnerable groups
 Fortification of essential foods – e.g., Iodized salt
 Popularization of low-cost nutritious food from indigenous and locally available
raw material.
 Control of micronutrient deficiencies amongst vulnerable groups
B. Indirect Intervention – Long Term
 Food security
 Improvement of production
 Improving the purchasing power:
 Poverty alleviation programmes
 Integrated rural development programme
 Employment generation schemes
 Public distribution system
 Land reforms
 Health and family welfare
 Basic health and nutrition knowledge
 Prevention of food adulteration
 Nutrition surveillance – organizations responsible
 Monitoring of nutrition programmes
9.5. POSHAN ABHIYAN (NATIONAL NUTRITION MISSION)
POSHAN Abhiyaan was launched by the Prime Minister on 8th March, 2018 in Jhunjhunu
district of Rajasthan. National Nutrition Mission or POSHAN Abhiyan is an overarching
umbrella scheme to improve the nutritional outcomes for children, pregnant women and
lactating mothers by holistically addressing the multiple determinants of malnutrition and
attempts to prioritize the efforts of all stakeholders on a comprehensive package of
intervention and services targeted on the first 1000 days of a child’s life.
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Aim and objectives: POSHAN’s goal is to support and strengthen policy and program
decisions and actions to accelerate reductions in maternal and child undernutrition in India
through an inclusive process of evidence synthesis, knowledge generation, and knowledge
mobilization.
Specific objectives of POSHAN are:
- Prevent and reduce Stunting in children (0- 6 years) It aims to reduce child stunting,
underweight and low birth weight by 2 percentage points per annum
- Prevent and reduce under-nutrition (underweight prevalence) in children (0-6 years)
- Reduce the prevalence of anaemia among young Children (6-59 months)
- Reduce the prevalence of anaemia among Women and Adolescent Girls in the age
group of 15-49 years by 3 percentage points per annum
- Reduce Low Birth Weight (LBW)
Components: It seeks to do so through an appropriate governance structure by leveraging

and intensifying the implementation of existing programs across multiple Ministries while at
the same time trying to rope in the expertise and energies of a whole range of other
stakeholders – State Governments, Communities, Think tanks, Philanthropic Foundations and
other Civil Society Actors. It is based on 4 pillars
 Ensuring access to quality services across the continuum of care to every woman and
child; particularly during the first 1000 days of the child’s life.
 Ensuring convergence of multiple programs and schemes: ICDS, PMMVY, NHM
(with its sub components such as JSY, MCP card, Anaemia Mukt Bharat, RBSK,
IDCF, HBNC, HBYC, Take Home Rations), Swachh Bharat Mission, National
Drinking water Mission, NRLM etc.
 Leveraging technology (ICDS-CAS) to empower the frontline worker with near real
time information to ensure prompt and preventive action; rather than reactive one.
ICDS-CAS is a Software based tracking of nutritional status will be done. AWWs and
Supervisors will be provided with mobile phone. Growth monitoring devices
(Stadiometer, infantometer, weighing scales (infant) and weighing scale (mother and
child) will be provided as well.
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 Jan Andolan to bring about a behavioural change: Engaging the community in this
Mission to ensure that it transcends the contours of being a mere Government
programme into a peoples’ movement inducing large scale behaviour change with the
ownership of the efforts being vested in the community rather than government
delivery mechanisms.
 Organizing community-based events on themes such as Annaprasan Diwas, Suposhan
Diwas, Celebrating coming of age – getting ready for preschool at AWC, Village
Health Sanitation Nutrition Day (VHSND)
9.6. SWACHH BHARAT ABHIYAAN

The Prime Minister of India had launched the Swachh Bharat Mission on 2nd October 2014.
The concept of Swachh Bharat Abhiyan is to provide basic sanitation facilities like toilets,
solid and liquid waste disposal systems, village cleanliness, and safe and adequate drinking
water supply to every person. Swachh Bharat Abhiyan is laid by the Ministry of Drinking
Water and Sanitation.
Aim: To accelerate the efforts to achieve universal sanitation coverage and to put the focus
on sanitation. Swachh Bharat Abhiyan is one of the most popular and significant missions in
the History of India. This campaign was launched to honour Mahatma Gandhi’s vision of a
clean country.
The major objective of the Swachh Bharat Abhiyan is to spread the awareness of cleanliness
and the importance of it.
Components: Constructing over 100 million toilets in rural India. Under the mission, all
villages, Gram Panchayats, Districts, States and Union Territories in India declared
themselves "open-defecation free" (ODF) by 2 October 2019. The mission is in campaign
mode.
Swachh Bharat Mission (Urban) 1.0: This comes under the Ministry of Urban
Development and is commissioned to give sanitation and household toilet facilities in all
4041 statutory towns with a combined population of 377 million. At the core of this mission
lie six components:
 Individual household toilets;
 Community toilets;
 Public toilets;
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 Municipal Solid Waste Management;

 Information and Education Communication (IEC) and Public Awareness;
 Capacity Building
Swachh Bharat Mission (Urban) 2.0: The components of SBM-Urban 2.0 are:
- New component – Wastewater treatment, including faecal sludge management in
all ULBs with less than 1 lakh population
- Sustainable sanitation (construction of toilets)
- Solid Waste Management
- Information, Education and Communication, and
- Capacity building
Swachh Bharat Mission (Rural): The Rural mission, known as Swachh Bharat Gram, aims
to make Village Panchayats open defecation free by:
- Removing obstacles and addressing critical issues that affect rural sanitation mission
- Removing the filth and unhygienic conditions in village schools
- Construction of Anganwadi toilets and management of solid and liquid waste
Ranking of cities: Every year, cities and towns across India are awarded the title of ‘Swachh
Cities’ based on their cleanliness and sanitation drive as a part of the Swachh Bharat Abhiyan
that was launched in 2014.
Swachh Tourist Destinations: Under the Swachh Bharat Mission, it has been decided to
undertake a special clean-up initiative focused on 100 iconic heritage, spiritual and cultural
places in the country. This initiative aims to make these 100 places model ‘Swachh Tourist
Destinations’, which will enhance the experience for visitors from India and abroad.
9.7. NATIONAL HEALTH POLICY 2017

NHP 2017 builds on the progress made since the last NHP 2002. After the last health policy,
the context has changed in four major ways:
- First, the health priorities are changing. Although maternal and child mortality have
rapidly declined, there is growing burden on account of noncommunicable diseases
and some infectious diseases.
- The second important change is the emergence of a robust health care industry
estimated to be growing at double digit.
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- The third change is the growing incidences of catastrophic expenditure due to health
care costs, which are presently estimated to be one of the major contributors to
poverty.
- Fourth, a rising economic growth enables enhanced fiscal capacity. Therefore, a new
health policy responsive to these contextual changes is required.
Aim: The primary aim of the National Health Policy, 2017, is to inform, clarify, strengthen
and prioritize the role of the Government in shaping health systems in all its dimensions.
Goal: The policy envisages as its goal the attainment of the highest possible level of health
and wellbeing for all at all ages, through a preventive and promotive health care orientation in
all developmental policies, and universal access to good quality health care services without
anyone having to face financial hardship as a consequence. The policy recognizes the pivotal
importance of Sustainable Development Goals (SDGs).
Objectives Improve health status through concerted policy action in all sectors and expand
preventive, promotive, curative, palliative and rehabilitative services provided through the
public health sector with focus on quality.
Thrust areas: Specific quantitative goals and objectives of the health policy include the
following thrust areas:
Health Status and Programme Impact
i. Life Expectancy and healthy life
a. Increase Life Expectancy at birth from 67.5 to 70 by 2025.
b. Establish regular tracking of Disability Adjusted Life Years (DALY) Index as
a measure of burden of disease and its trends by major categories by 2022.
c. Reduction of TFR to 2.1 at national and sub-national level by 2025.
ii. Mortality by Age and/ or cause
a. Reduce Under Five Mortality to 23 by 2025 and MMR from current levels to
100 by 2020.
b. Reduce infant mortality rate to 28 by 2019.
c. Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
iii. Reduction of disease prevalence/ incidence
o Achieve global target of 2020 for HIV/AIDS
o Elimination of Leprosy, Kala-Azar and Lymphatic Filariasis
o To reach elimination status of TB by 2025.
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o To reduce the prevalence and disease burden of blindness.

o To reduce premature mortality from cardiovascular diseases, cancer, diabetes
or chronic respiratory diseases by 25% by 2025.
Health Systems Performance
i. Coverage of Health Services
ii. Cross Sectoral goals related to health
Health Systems strengthening
i. Health finance and expenditure
ii. Health Infrastructure and Human Resource
iii. Health Management Information
Policy thrust
i. Ensuring Adequate Investment - The policy proposes a potentially achievable target
of raising public health expenditure to 2.5% of the GDP in a time bound manner.
ii. Preventive and Promotive Health - The policy identifies coordinated action on seven
priority areas for improving the environment for health:
a. The Swachh Bharat Abhiyan
b. Balanced, healthy diets and regular exercises.
c. Addressing tobacco, alcohol and substance abuse
d. Yatri Suraksha – preventing deaths due to rail and road traffic accidents
e. Nirbhaya Nari – action against gender violence
f. Reduced stress and improved safety in the work place
g. Reducing indoor and outdoor air pollution
iii. Organization of Public Health Care Delivery - The policy proposes seven key policy
shifts in organizing health care services.
9.8. NATIONAL FOOD SECURITY ACT 2013

'Food security' at the household is continuously being addressed by the Government since
long, through the Public Distribution System and the Targeted Public Distribution System. A
step forward is the enactment of the National Food Security Act, (NFSA) 2013. This act
came into force on July 5, 2013.
The basic concept of food security globally is to ensure that all people, at all times, should get
access to the basic food for their active and healthy life and is characterized by availability,
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access, utilization and stability of food. Though the Indian Constitution does not have any
explicit provision regarding right to food, the fundamental right to life enshrined in Article 21
of the Constitution may be interpreted to include right to live with human dignity, which may
include the right to food and other basic necessities.
Objective: NFA, 2013 enshrines a paradigm shift in the approach to food security from
welfare to rights-based approach.
Coverage and entitlement under NFSA: NFSA covers both rural population and urban
population under Antyodaya Anna Yojana (AAY) and priority households. While AAY
households, which constitute poorest of the poor are entitled to 35 kg of foodgrains per
family per month, priority households are entitled to 5 kg per person per month.
The Act legally entitles upto 75% of the rural population and 50% of the urban population to
receive subsidized foodgrains under Targeted Public Distribution System. As a step towards
women empowerment, the eldest woman of the household of age 18 years or above is
mandated to be the head of the household for the purpose of issuing of ration cards under the
Act. The Act is being implemented in all the States/UTs, and on an all-India basis.
Provisions of the act: One of the guiding principles of the Act is its life-cycle approach
wherein special provisions have been made for pregnant women and lactating mothers and
children in the age group of 6 months to 14 years, by entitling them to receive nutritious meal
free of cost through a widespread network of Integrated Child Development Services (ICDS)
centres, called Anganwadi Centres under ICDS scheme and also through schools under Mid-
Day Meal (MDM) scheme. Higher nutritional norms have been prescribed for malnourished
children upto 6 years of age. Pregnant women and lactating mothers are further entitled to
receive cash maternity benefit of not less than Rs. 6,000 to partly compensate for the wage
loss during the period of pregnancy and also to supplement nutrition.
9.9. THE INDIAN COUNCIL OF AGRICULTURAL RESEARCH (ICAR)

ICAR is an autonomous organisation under the Department of Agricultural Research and
Education (DARE), Ministry of Agriculture and Farmers Welfare, Government of India.
Formerly known as Imperial Council of Agricultural Research, it was established on 16 July
1929 as a registered society under the Societies Registration Act, 1860 in pursuance of the
report of the Royal Commission on Agriculture. The ICAR has its headquarters at New
Delhi.
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Objective: The Council is the apex body for co-ordinating, guiding and managing research
and education in agriculture including horticulture, fisheries and animal sciences in the entire
country. With 111 ICAR institutes and 71 agricultural universities spread across the country
this is one of the largest national agricultural systems in the world.
Important achievements: Important achievements of ICAR are:
- The ICAR has played a pioneering role in ushering Green Revolution and
subsequent developments in agriculture in India through its research and
technology development that has enabled the country since 1950-51 to 2017-18 to
increase the production of –
. foodgrains by 5.6 times
. horticultural crops by 10.5 times
. fish by 16.8 times
. milk by 10.4 times
. eggs by 52.9 times
- It has made a visible impact on the national food and nutritional security.
- It has played a major role in promoting excellence in higher education in
agriculture.
- It is engaged in cutting edge areas of science and technology development and its
scientists are internationally acknowledged in their fields.
Mandate of ICAR: The mandate of the Indian Council of Agricultural Research is:
- To plan, undertake, aid, promote and coordinate education, research and its
application in agriculture, agroforestry, animal husbandry, fisheries, home science and
allied sciences.
- To act as a clearing house of research and general information relating to agriculture,
animal husbandry, home science and allied sciences, and fisheries through its
publications and information system; and instituting and promoting transfer of
technology programmes.
- To provide, undertake and promote consultancy services in the fields of education,
research, training and dissemination of information in agriculture, agroforestry,
animal husbandry, fisheries, home science and allied sciences.
- To look into the problems relating to broader areas of rural development concerning
agriculture, including postharvest technology by developing co-operative programmes
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with other organizations such as the Indian Council of Social Science Research,
Council of Scientific and Industrial Research, Bhabha Atomic Research Centre and
the universities.
- To do other things considered necessary to attain the objectives of the Society.
9.10. THE INDIAN COUNCIL OF MEDICAL RESEARCH (ICMR)

ICMR New Delhi, the apex body in India for the formulation, coordination and
promotion of biomedical research, is one of the oldest medical research bodies in the world
(more than hundred years in the service of bio-medical research). As early as in 1911, the
Government of India set up the Indian Research Fund Association (IRFA) with the specific
objective of sponsoring and coordinating medical research in the country. After
independence, several important changes were made in the organization and the activities of
the IRFA. It was re-designated in 1949 as the Indian Council of Medical Research (ICMR)
with considerably expanded scope of functions.
Aim: The ICMR is funded by the Department of Health Research (DHR), Ministry of Health
& Family Welfare, Government of India. It promotes research in all areas of medical and
related science with an aim of - improving the health and quality of life of the Indian public.
The Council has broadened its activities from a pure biomedical research organization to one
that also undertakes health systems research.
Mandate of ICMR: Efforts are undertaken with a view to reduce the total burden of disease
and to promote health and well-being of the population. Its mandate covers the entire
spectrum of research from biological to social, laboratory to field, and from idea to use. The
Council commits itself to take its research agenda forward, and strives to get research results
translated into efficient disease control and prevention strategies.
The Council’s research priorities coincide with the national health priorities such as –
- control and management of communicable diseases
- fertility control
- maternal and child health
- control of nutritional disorders
- developing alternative strategies for health care delivery
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- containment within safety limits of environmental and occupational health problem

- research on major noncommunicable diseases like cancer, cardiovascular diseases,
blindness, diabetes and other metabolic and haematological disorders,
- mental health research and drug research (including traditional remedies).
Features of ICMR: The Governing Council of ICMR is presided over by the Union Minister
for Health and Family Welfare, GOI. It is assisted in scientific and technical matters by a
Scientific Advisory Board comprising of eminent experts in different biomedical disciplines.
The Board, in its turn, is assisted by a series of Scientific Advisory Groups, Scientific
Advisory Committees, Expert Groups, Task Forces and Steering Committees etc. which
evaluate and monitor different research activities of the Council.
The ICMR promotes biomedical research in the country through intramural as well as
extramural research. Intramural research is carried out currently through the Council’s 32
Research Institutes/ Centres/Units. ICMR works to strengthen and streamline medical
informatics and communication to meet the growing demands and needs of the biomedical
community. The Council is alert to new diseases and new dimensions of existing diseases, as
exemplified by the rapid organization of a network of Surveillance Centres for AIDS in
different states of India in 1986 and COVID in last few years.In addition to research
activities, the ICMR encourages human resource development in biomedical research
through- Research Fellowships; Short-Term Visiting Fellowships; Short-Term Research
Studentships and; Various Training Programmes and Workshops conducted by ICMR
Institutes and Headquarters.
9.11. NATIONAL INSTITUTE OF NUTRITION (NIN)

NIN was founded by Sir Robert McCarrison in the year 1918 as ‘Beri-Beri’ Enquiry Unit in a
single room laboratory at the Pasteur Institute, Coonoor, Tamil Nadu. Within a short span of
seven years, this unit blossomed into a "Deficiency Disease Enquiry" and later in 1928,
emerged as full-fledged "Nutrition Research Laboratories" (NRL) with Dr. McCarrison as its
first Director. It was shifted to Hyderabad in 1958. At the time of its golden jubilee in 1969, it
was renamed as National Institute of Nutrition (NIN).
Objectives: Objectives of the institute are:
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- To identify various dietary and nutrition problems prevalent among different

segments of the population in the country.
- To continuously monitor diet and nutrition situation of the country.
- To evolve effective methods of management and prevention of nutritional problems.
- To conduct operational research connected with planning and implementation of
national nutrition programmes.
- To dovetail nutrition research with other health programmes of the government.
- Human resource development in the field of nutrition.
- To disseminate nutrition information.
- To advise governments and other organisations on issues relating to nutrition
Mandate: Mandate of National institute of nutrition is to:
 Provide Evidence: Evidence based inputs on food and nutrient consumption patterns;
trends in nutrition status of population across age and physiological groups; Micro
and Macronutrient values of foods, maternal and child nutrition, NCD biomarkers,
Environmental pollution/toxins affecting health, Drug nutrient interaction, Nutrition
and immune response.
 Providing Guidelines: Recommended Dietary Allowances (RDA), Dietary Guidelines
for Indians, Diet and Diabetes, Diet and Heart Diseases, Diet during Pregnancy
(region-specific guidelines), Nutrition and Infection
 Influence Policies: National Nutrition programmes such as Integrated Child
Development Services (ICDS), Mind-day Meal (MDM) programme, Clinical
Management – Severe Acute Malnutrition (CM-SAM) & many state level Nutrition
programs; Vitamin A prophylaxis, Iron and Folic Acid Supplementation, Double
Fortification of Salt (DFS) with iron and iodine, Recommendations on vegetable oils
Food fortification guidelines to the Food Safety and Standards Authority of India (-
FSSAI), Food and ground water regulations.
 Raise Awareness: We broaden knowledge and understanding of how nutrition and
balanced diets coupled with physical activity and lifestyles can help improve mental
and physical wellbeing and how they can reduce communicable and non-
communicable diseases by developing tools, sharing best practices, and holding
engaging public events. NIN Mob App, e- Learning modules and host of videos and
pamphlets.
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 Developing Human Resource: Two full time MSc courses, short term certificate
courses, Ph.Ds, two training programmes for medical college faculty and public
health personnel, Anthropometry assessment, Nutrition & Dietary assessment,
National fluorosis training, PCT for regulatory bodies, Animal handling. Added to
these, custom-made training programmes on demand in adhoc mode.
 Need based support during public health emergencies: Extending support to
Governments/ICMR to explore, assess and combat public health issues and outbreaks.
9.12. NATIONAL NUTRITION MONITORING BUREAU (NNMB)

Monitoring of the nutritional status of population, is an important aspect of any nutrition
intervention programme to assess the massive inputs and to determine the direction in which
the community nutrition is progressing, so as to initiate appropriate corrective actions. The
Indian Council of Medical Research (ICMR), established National Nutrition Monitoring
Bureau (NNMB) in the year 1972, with a Central Reference Laboratory (CRL) at the
National Institute of Nutrition, Hyderabad.
Objectives: The objectives of NNMB are:
- To collect data on dietary intakes and nutritional status of the population on a
continuous basis.
- To evaluate the ongoing national nutrition programmes.
- In addition to coordinating the activities of the State units, CRL is also responsible for
sampling, training, supervision and analysis of the data collected periodically.
Linkages with the National Sample Survey Organization have also been forged. At
present there are 10 units of NNMB in different states of India i.e., Andhra Pradesh,
Gujarat, Orissa, Karnataka, Kerala, Madhya Pradesh, Tamil Nadu.
Discontinuation of NNMB: Forty years after being established with a mandate to generate
data on the nutritional status of socially vulnerable groups, the National Nutrition Monitoring
Bureau (NNMB) has been shut down by the Union Health Ministry.
Reason for shutting down of NNMB: The bureau was running in a project mode.
Government programmes that run in a project mode for this long are not sustainable.
Therefore, the ICMR was asked to shut down the project by the union ministry of health.
Emergence of National Family Health Survey (NFHS): Prior to the first NFHS 1 in 1992,
the only data available on undernutrition was limited to 10 states through the National
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Nutrition Monitoring Bureau (NNMB). Following the NFHS 1, four national surveys have
been conducted: NFHS2 (1998-99), NFHS 3 (2005-6), NFHS 4 (2015-16), and NFHS 5
(2019-20). It aims at including all states and union territories.
The National Family Health Survey is a survey carried out on a massive scale across the
country to collect information on many parameters which would ultimately help the Ministry
of Health and Family Welfare (MOHFW) to frame policies and programs to help in the
upliftment of the vulnerable groups in India. The first round of the National Family Health
Survey was conducted in 1992-92. Subsequently, four other rounds have taken place, the
latest being NFHS 5 that started in 2018-19
Nodal agency of NFHS: International Institute for Population Sciences, IIPS, Mumbai is the
nodal agency that conducts NFHS. Earlier Ministry of Health itself conducted District Level
Health Survey, DLHS and Annual Health Survey, AHS.
9.13. THE FOOD AND NUTRITION BOARD (FNB)

FNB was set up in 1964, is under the department of Women welfare and Child Development.
The FNB has a technical wing at the centre, four regional offices at Delhi, Mumbai, Kolkata
and Chennai.
Objective: It is engaged in its conventional activities as well as in new initiatives undertaken
as a follow up of National Nutrition Policy.
Components: Some of the areas of FNB activities are as under.
 Nutrition Education and Orientation: Nutrition Education of the people in rural, urban
and tribal areas is one of the primary activities of the FNB. Nutrition demonstrations
in rural, urban and tribal areas are organized by each of the 43 Community Food and
Nutrition Extension Units (CFNEUS) in different states, 12,000 programmes
benefiting about 5 lakh persons are organized annually.
 Training in Home Scale Preservation of Fruits and Vegetable: The CFNEUS impart
education and training in home scale preservation of fruits and vegetables to
housewives and adolescent girls with a view to promote preservation and
consumption of fruits and vegetable which could be useful for income generation
purposes.
 Monitoring of Supplementary Feeding under ICDS: The CFNEUS monitor the
supplementary feeding component of ICDS in areas of their location.
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 Mass Media Communication: Development of educational and training material on

nutrition has been one of the important activities of FNB Headquarters. Some of the
important publications include Handbook on Integrated Nutrition Education,
Guidelines for Nutrition of pregnant women, posters on child’s Health, Nursing
mothers, complementary feeding, instant food mixes, Iodized salt, folders on mother’s
milk, green leafy vegetables, fruits and vegetables for vitality, stickers for school
children, National plan of Action on Nutrition etc. Efforts are made to promote
nutrition facts about infants, pregnant and lactating mothers.
 Advocacy and Sensitization of Policy makers and Programme managers: Advocacy
and sensitization of policy makers for integrating nutritional concerns in
developmental programmes is a key issue for promoting nutrition of the people in the
country. Regional workshops are planned for this.
 Follow Up Action on National Nutrition Policy: A number of initiatives have been
taken up since National Nutrition Policy was adopted by Government of India in
1993. A National Plan of Action on Nutrition was formulated and approved by the
Inter-ministerial coordination Committee and released in 1995. A task force on
micronutrient deficiency like Vitamin A and Iron was constituted and details are
worked to eradicate them.
9.14. NUTRITION FOUNDATION OF INDIA (NFI)

Nutrition Foundation of India (NFI) was founded by Dr.C.Gopalan in 1980 with the active
co-operation and support of a large body of scientists and leading citizens. NFI is a non-
governmental, non-profit, voluntary institution dedicated to the cause of eradication of under
nutrition in the country. It is recognized officially by the government of India as a “scientific
research body”.
The foundation derives financial support for its activities from enlightened private donors and
from National and International agencies interested in the improvement of nutritional status
of populations. The government of India’s continued support and goodwill facilitated the
growth of the foundation.
Objectives: NFI Highlights and focus public and government attention on national problems
related to malnutrition: assess their causation, magnitude and implications and offer short
term as well as long term action plans for their control.
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Activities: Institute conduct and support action-oriented studies and research on these
problems through existing institutes, university centres and other suitable bodies in order to
evolve appropriate solutions capable of application in the current context. It also Investigate
means to offset existing deficiencies in the pattern of production and distribution of foods and
to ensure wholesomeness and nutritive value of foods sold for public consumption. It
undertakes dissemination information on diet and nutrition, promote nutrition education in
schools and through mass media, publish periodically a Bulletin in order to disseminate
information on important facts of nutrition. Foundation has also set up a separate body which
deals with dietary and nutritional management of nutrition related chronic degenerative
disease.
CHECK YOUR PROGRESS
Expand the following terms
i. MDG
ii. SDG
iii. NNMB
iv. NFHS
v. ICAR
vi. ICMR
vii. NIN
viii. NFI
ix. NNM
x. FNB

1. List the 17 SDGs
2. List the major national nutrition surveys.
3. Write about Indirect interventions outlined in NNP 1993.
4. What are the aims and objectives of National Nutrition Mission?
5. What are the components of Swachch Bharat Mission?
6. What are the major thrust areas envisaged in the National Health Policy 2017?
7. What basic concept of National food security act 2013?
8. What is the impact of ICAR on food security?
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9. What is the aim of ICMR?

10. When was NIN founded?
11. What was the reason to shut down NNMB?
12. After NNMB Which organization has stepped in to continue nutrition surveillance in
India?
9.15. SUMMARY
Public policy is important because policy choices and decisions made by those in power
affect nearly every aspect of daily life, including education, healthcare and national security.
The policies set in place by officials at all level of government establish rules, regulations and
procedures that guide the actions of citizens within their jurisdiction. Nutrition affects
development and converse is also true. Policies are influenced by both global decisions and
domestic actions. Globally policies have shifted focus from food production as the solution to
world hunger to include nutrition security as well as food security for which the United
Nations, Millennium Development Goals (MDGs) were drawn. Recently in 2015 SDGs were
set up by the United Nations General Assembly (UN-GA) with the focus of SDGs is
comprehensive sustainability. The national nutrition policy adopted in 1993 suggests both
direct and indirect policy interventions. Recently several nutrition and health policies,
programs or acts have come in action such as POSHAN, Swachh Bharat Abhiyaan, National
Health Policy 2017 and National Food Security Act 2013. Several national agencies that
have played an important role in surveillance and influencing policies governing food and
nutrition security, such as, ICAR, ICMR, NIN, NNMB, FNB and NFI.
9.16. GLOSSARY
Word Meaning
Millennium The definition of a millennium is a period of 1000 years or is an
anniversary of the passage of 1000 years. An example of a millennium
is the 1000 years from year 1000 to the year 2000. The year 2000 was
an example of the millennium.
Sustainable Sustainable development can be defined as an approach to the
development development of a country without compromising with the quality of the
environment for future generations.
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Multisectoral Multi-sectoral means something that consists of many sectors. When we

talk of multi-sectoral approach, it is in an approach in which we try to
address the problem from various angles. It means the collaboration
between the relevant stakeholders to jointly prevent and respond to
problems.
Overarching All embracing, comprehensive or encompassing or linking all that is
within its scope, range, etc.
Stadiometer A device used to measure body height, especially of children.
Infantometer The infantometers is used to measure the length of infants in order to
regularly assess growth
AAY household Antyodaya Anna Yojana (AAY) households are poorest of the
poor households in the country.
Autonomous An Autonomous Body (AB) is set up by the government for a specific
organization purpose. It is independent in day-to-day functioning, but the
government has some control over it.

1. National food security portal, Ministry of food and civil supplies, GOI, National Food
Security Act 2013, https://nfsa.gov.in/portal/NFSA-Act, DOA 25-10-22
2. Government Of India Ministry of Women & Child Development, 1993, National
Nutrition Policy, New Delhi
3. Vir, S., K. C. Sreenath, V. Bose, K. Chauhan, S. Mathur, and S. Menon. 2014.
National Policies and Strategic Plans to Tackle Undernutrition in India: A Review.
POSHAN Report No. 2. New Delhi: International Food Policy Research Institute.
Expand the following terms

i. MDG - Millennium Development Goals
ii. SDG - Sustainable Development Goals
iii. NNMB- National Nutrition Monitoring Bureau
iv. NFHS- National Family Health Survey
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v. ICAR- Indian Council of Agricultural Research

vi. ICMR- Indian Council of Medical Research
vii. NIN- National Institute of Nutrition
viii. NFI- Nutrition Foundation of India
ix. NNM- National Nutrition Mission
x. FNB- Food and Nutrition Board

1. List the 17 SDGs.
1) No poverty
2) Zero hunger
3) Good health and well-being
4) Quality education
5) Gender equality
6) Clean water and sanitation,
7) Affordable and clean energy
8) Decent work and economic growth
9) Industry, innovation and infrastructure
10) Reduced Inequality
11) Sustainable Cities and Communities
12) Responsible Consumption and Production
13) Climate Action,
14) Life Below Water
15) Life on Land
16) Peace, Justice, and Strong Institutions
17) Partnerships for the Goals
2. List the major national nutrition surveys.
The major national surveys include the National Family Health Surveys (NFHS),
District Level Household Survey (DLHS), Annual Health Survey (AHS), National
Nutrition Monitoring Bureau (NNMB) Survey, Rapid Survey on Children (RSoC) and
Comprehensive National Nutrition Survey (CNNS)
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3. Write about Indirect interventions outlined in NNP 1983.

Indirect Intervention are those interventions that are expected to have a long term
impact. The programmes and policies in the following areas are considered under the
indirect policy intervention. These are:
 Food security
 Improvement of production
 Improving the purchasing power:
 Poverty alleviation programmes
 Integrated rural development programme
 Employment generation schemes
 Public distribution system
 Land reforms
 Health and family welfare
 Basic health and nutrition knowledge
 Prevention of food adulteration
 Nutrition surveillance
 Monitoring of nutrition programmes
4. What are the aims and objectives of National Nutrition Mission?

POSHAN’s goal is to support and strengthen policy and program decisions and
actions to accelerate reductions in maternal and child undernutrition in India through
an inclusive process of evidence synthesis, knowledge generation, and knowledge
mobilization. Specific objectives of POSHAN are:
 Prevent and reduce Stunting in children (0- 6 years) It aims to reduce child
stunting, underweight and low birth weight by 2 percentage points per annum
 Prevent and reduce under-nutrition (underweight prevalence) in children (0-6
years)
 Reduce the prevalence of anaemia among young Children (6-59 months)
 Reduce the prevalence of anaemia among Women and Adolescent Girls in the
age group of 15-49 years by 3 percentage points per annum
 Reduce Low Birth Weight (LBW)
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5. What are the components of Swachch Bharat Mission?

Under the mission, all villages, Gram Panchayats, Districts, States and Union
Territories in India declared themselves "open-defecation free" (ODF) by 2019. The
mission is in campaign mode. Its major components include:
 Swachh Bharat Mission (Urban) 1.0: This comes under the Ministry of
Urban Development and is commissioned to give sanitation and household
toilet facilities in all 4041 statutory towns with a combined population of 377
million. At the core of this mission lie six components:
1) Individual household toilets
2) Community toilets
3) Public toilets
4) Municipal Solid Waste Management
5) Information and Education Communication (IEC) and Public
Awareness
6) Capacity Building
 Swachh Bharat Mission (Urban) 2.0: The components of SBM-Urban 2.0
are:
1) New component – Wastewater treatment, including faecal sludge
management in all ULBs with less than 1 lakh population
2) Sustainable sanitation (construction of toilets)
3) Solid Waste Management
4) Information, Education and Communication, and
5) Capacity building
 Swachh Bharat Mission (Rural): The Rural mission, known as Swachh
Bharat Gramin, aims to make Village Panchayats open defecation free by:
i. Removing obstacles and addressing critical issues that affect rural
sanitation mission
ii. Removing the filth and unhygienic conditions in village schools
iii. Construction of Anganwadi toilets and management of solid and liquid
waste
 Ranking of cities
 Swachh Tourist Destinations
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6. What are the major thrust areas envisaged in the National Health Policy 2017?
Specific quantitative goals and objectives of the health policy include the following thrust
areas:
Health Status and Programme Impact
iv. Life Expectancy and healthy life
v. Mortality by Age and/ or cause
vi. Reduction of disease prevalence/ incidence
Health Systems Performance
iii. Increase coverage of Health Services
iv. Cross Sectoral goals related to health e.g. reducing current tobacco use, Reduction of
40% in prevalence of stunting of under-five children by 2025, Access to safe water
and sanitation to all by 2020 (Swachh Bharat Mission).
Health Systems strengthening
iv. Improve Health finance
v. Health Infrastructure and Human Resource
vi. Health Management Information
Policy thrust
iv. Ensuring Adequate Investment
v. Preventive and Promotive Health
vi. Organization of Public Health Care Delivery
7. What basic concept of National food security act 2013?

The basic concept of food security globally is to ensure that all people, at all times,
should get access to the basic food for their active and healthy life and is characterized
by availability, access, utilization and stability of food. Though the Indian Constitution
does not have any explicit provision regarding right to food, the fundamental right to
life enshrined in Article 21 of the Constitution may be interpreted to include right to
live with human dignity, which may include the right to food and other basic
necessities.
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8. What is the impact of ICAR on food security?

The ICAR has played a pioneering role in ushering Green Revolution and subsequent
developments in agriculture in India through its research and technology development
that has enabled the country since 1950-51 to 2017-18 to increase the production of –
. foodgrains by 5.6 times
. horticultural crops by 10.5 times
. fish by 16.8 times
. milk by 10.4 times
. eggs by 52.9 times
- It has made a visible impact on the national food and nutritional security.
- It has played a major role in promoting excellence in higher education in
agriculture.
- It is engaged in cutting edge areas of science and technology development and its
scientists are internationally acknowledged in their fields.
9. What is the aim of ICMR?

The ICMR is funded by the Department of Health Research (DHR), Ministry of Health
& Family Welfare, Government of India. It promotes research in all areas of medical
and related science with an aim of - improving the health and quality of life of the
Indian public. The Council has broadened its activities from a pure biomedical
research organization to one that also undertakes health systems research.
10. When was NIN founded?

NIN was founded by Sir Robert McCarrison in the year 1918 as ‘Beri-Beri’ Enquiry
Unit in a single room laboratory at the Pasteur Institute, Coonoor, Tamil Nadu. Within
a short span of seven years, this unit blossomed into a "Deficiency Disease Enquiry"
and later in 1928, emerged as full-fledged "Nutrition Research Laboratories" (NRL)
with Dr. McCarrison as its first Director. It was shifted to Hyderabad in 1958. At the
time of its golden jubilee in 1969, it was renamed as National Institute of Nutrition
(NIN).
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11. What was the reason to shut down NNMB?

The bureau was running in a project mode. Government programmes that run in a
project mode for this long are not sustainable. Therefore, the ICMR was asked to shut
down the project by the union ministry of health.
12. After NNMB Which organization has stepped in to continue nutrition

surveillance in India?
National Family Health Survey (NFHS) has emerged as the new national nutrition
surveillance of Prior to the first NFHS 1 in 1992, the only data available on
undernutrition was limited to 10 states through the National Nutrition Monitoring
Bureau (NNMB). Following the NFHS 1, four national surveys have been conducted:
NFHS2 (1998-99), NFHS 3 (2005-6), NFHS 4 (2015-16), and NFHS 5 (2019-20).
Aim of NFHS is to cover all states and union territories.
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UNIT-10: NATIONAL AND GLOBAL NUTRITION PROGRAMS- ICDS, WHO,

UNICEF, FAO, CARE AND MIDDAY MEAL
STRUCTURE
10.1. OBJECTIVES
10.2. INTRODUCTION
10.3. INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)
10.4. UNITED NATIONS CHILDREN’S FUND (UNICEF)
10.5. WORLD HEALTH ORGANIZATION (WHO)
10.6. THE FOOD AND AGRICULTURAL ORGANIZATION (FAO)
10.7. COOPERATIVE AMERICAN RELIEF EVERYWHERE (CARE)
10.8. MID-DAY MEAL SCHEME (PM POSHAN SCHEME)
10.9. SUMMARY
10.10. GLOSSARY
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10.1. OBJECTIVES
• Understand about the global and national programs related to nutrition.
• Understand about the national and global agencies involved directly or indirectly to
combat the major nutritional problems.
10.2. INTRODUCTION
According to the latest National Family Health Survey (NFHS-5), India has seen no
significant improvement in health and nutritional status among her population. Overweight or
obesity is also on the rise among Indian adult male and females. India is home to nearly 200
million undernourished people. The COVID 19 pandemic and subsequent lockdown has
made food insecurity worse by disrupting the food distribution system across large parts of
India.
Nutrition programmes are key turning points in implementation strategies leading to food and
nutrition improvement as a sound basis for socio-economic development. In order to be
effective and successful, they require an multi-pronged services with focused planning along
with policy support for effective implementation, reaching the unreachable and empowering
those at the grass roots. They need to be guided and monitored using a set of indicators
specific to the community's needs. The community-based approach has been embraced at the
global level with the Sustainable Development Goals, advocating achieving a set of
seventeen goals ranging from reducing poverty and hunger to improving educational
opportunities for all children and forming stronger global partnerships for development with
sustainability as the underlying goal. The Government of India established the NITI Aayog to
attain sustainable development goals or the “Agenda 2030”. National level leadership and
commitment to sound nutrition improvement policies and goals, must be combined with basic
services, social mobilization and actions at community level.
10.3. INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)

Integrated Child Development Service (ICDS) scheme was launched on 2nd October, 1975
(5th five-year Plan) in pursuance of the National Policy for Children in 33 experimental
blocks. Now the goal is to universalize ICDS throughout the country. The primary
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responsibility for the implementation of the programme is with the Department of Women
and Child Development, Ministry of Human Resources Development at the Centre and the
nodal departments at the state which may be Social Welfare, Rural Development, Tribal
Welfare, Health and Family Welfare or Women and Child Development.
Objectives
 Improve the nutrition and health status of children in the age group of 0-6 years
 Lay the foundation for proper psychological, physical and social development of the
child
 Effective coordination and implementation of policy among the various departments
 Enhance the capability of the mother to look after the normal health and nutrition
needs through proper nutrition and health education.
 To reduce the incidence of mortality, morbidity, malnutrition and school dropout
ICDS Provisions and Services

Integrated Child Development Services is Centrally-Sponsored and will provide the
following six services to the beneficiaries:
1. Supplementary Nutrition (SNP)
2. Health & Nutrition Check-Up
3. Immunization
4. Non-Formal Education for Children in Pre-School
5. Health and Nutrition Education
6. Referral services
These services are provided from Anganwadi centres established mainly in rural areas and
staffed with frontline workers.
Supplementary Nutrition Programme (SNP): Under this segment of the ICDS, children
below 6 years and pregnant and lactating mothers are identified within the community and
are provided with supplementary feeding and growth monitoring services. The beneficiaries
are given 300 days of supplementary feeding. By giving supplementary feeding, the scheme
tries to bridge the caloric gap between the national recommended and average intake of
children and women in low-income categories.
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Health and Nutrition Check-Up: This includes healthcare of children under six years of
age, antenatal care of pregnant women and postnatal care of nursing mothers. Services
offered include regular health check-ups, treatment of diarrhoea, deworming, weight
recording, immunizations and distribution of simple medicines.
Immunization: Children are given vaccinations against the following preventable diseases:
diphtheria, polio, pertussis, measles, TB and tetanus. Pregnant women are given vaccinations
against tetanus that reduced neonatal and maternal mortality.
Non-Formal Education for Children in Pre-School (PSE): This segment can be deemed to
be the backbone of the ICDS scheme. All the services of the scheme converge at the
Anganwadi centres in villages and rural areas, and urban slums. This preschool educational
programme mainly for underprivileged children is directed towards providing and ensuring a
natural, joyful and stimulating environment, with emphasis on necessary inputs for optimal
growth and development. The early learning component of the ICDS is a significant input for
providing a sound foundation for cumulative lifelong learning and development. It offers the
child the necessary preparation for primary schools and also frees older siblings (particularly
girls) from taking care of younger children in the family and thus enabling them to attend
schools.
Health and Nutrition Education: Under this component, women in the age group of 15 to
45 years are covered for providing Nutrition and Health Education. This forms part of BCC
(Behaviour Change Communication) strategy. The long-term goal is to build the capacities of
women to enable them to look after their own health, nutrition and development needs as well
as that of their children and families.
Referral Services: During the regular health check-ups, any case of conditions or diseases
requiring immediate medical attention is referred to the hospital or any primary health centre,
etc. The Anganwadi worker is also trained to detect disabilities in children so that early
intervention can be done.
Beneficiaries of ICDS Provisions

Beneficiaries of the ICDS are the vulnerable sections belonging to rural areas, urban slums
and tribal areas. They include children below 6 years, pregnant and lactating women, women
in the age group of 15-44 years and adolescent girls in selected blocks. The target
beneficiaries for each of the services are indicated below in table-1.
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Table-1: The target beneficiaries for each of the services provided by ICDS
Services Targeted Beneficiary
Supplementary Nutrition Programme (SNP) Pregnant and lactating women.
Children under 6 years of age
Health & Nutrition Check-Up Pregnant and lactating women.
Immunization Pregnant and lactating women.
Non-Formal Education for Children in Pre- Children under 6 years of age
School
Health and Nutrition Education Pregnant and lactating women.
Referral services Pregnant and lactating women.
Achievements of ICDS
ICDS is the world’s largest government-owned, community-based outreach program for early
child development. In financial year 2021, more than 89 million mothers and children
benefitted under Integrated Child Development Scheme in India. Currently 13.87
lakh Anganwadi and mini-Anganwadi centres (AWCs/mini-AWCs) are operational out of
13.99 lakh sanctioned. The beneficiaries covered under ICDS include children up to the age
of six, pregnant women, and lactating mothers.
It is in operation for more than 45 years, and is still being examined for the many challenges
it poses in terms of efficiency, reach, vulnerability to malpractice, and effectiveness in being
able to deliver good nutrition where needed the most. The ICDS Scheme is still being
implemented as a scheme that provides food and take-home rations to communities in many
states, and its great potential as an Early Childhood Care and Education initiative has not
been explored to the fullest extent.
The change recommended by specialists is to build a localized response through
decentralization and flexibility in implementation, besides focusing more sharply on children
under 3 years of age. It is evident, however, from the dimensions of the burden that much
remains to be done, particularly if action has to be accelerated.
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10.4. UNITED NATIONS CHILDREN’S FUND (UNICEF)

The United Nations Children’s fund was created by the United Nations General assembly on
December 11, 1946, to provide emergency food and health care to children in countries that
had been devasted by World War II in 1953. The headquarter is present in New York city.
UNICEF provides long term humanitarian and developmental assistance to children and
mothers in developing countries.
Mandate of UNICEF
UNICEF works in over 190 countries and territories to save children's lives, to defend their
rights, and to help them fulfil their potential, from early childhood through adolescence.
UNICEF insists that the survival, protection and development of children are universal
imperatives. UNICEF works towards comprehensive child health care in the earliest years
including the antenatal period before birth.
Objectives
UNICEF’s stated aims are “to advocate for the protection of children’s rights, to help meet
their basic needs and to expand their opportunities to reach their full potential.” UNICEF
initiates programs and projects to achieve these aims and objectives.
Areas and priorities
Basic Education and Gender Equality: To promote fund and facilitates for universal primary
education for all and quality education and skill building.
Vaccines: UNICEF is the world’s largest provider of vaccines.
Emergencies: Before, during and after humanitarian emergencies, UNICEF is on the ground,
bringing lifesaving help and hope to children and families.
AIDS and Children: UNICEF also works via advocacy and community outreach to help
governments, communities and families support children orphaned by HIV/AIDS. UNICEF
also support programmes that help prevent mother-to child transmission of HIV/AIDS.
Child Protection: Focus areas include raising government awareness of child protection rights
and situation analysis as well as promoting laws that punish child exploiters working through
advocacy and the local offices worldwide. UNICEF helps strengthen the resources of schools
communities and families to care for marginalized children, including those orphaned by
HIV/AIDS.
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Nutrition and Health Programmes: It has maintained a vigorous programme of financial

assistance to maternal and child health problems in under developed areas. Distribution of
supplementary food to children has been accompanied increasingly by educational measures.
Its activities cover immunization, Vitamin A supplementation, Fe Supplementation and
education programmes. Support safe water and sanitation.
SDGs and UNICEF
The SDGs cannot be achieved without the realization of child rights. As world leaders work
to deliver on the 2030 promise, children around the globe are standing up to secure their right
to good health, quality education, a clean planet and more. The leaders of tomorrow,
children’s ability to protect the future for us all depends on what we do to secure their rights
today.
More than 100 Member States have renewed their commitment to children’s rights in the
context of implementing the SDGs. UNICEF works with governments, partners and other UN
agencies to help countries ensure the goals deliver results for and with every child – now and
for generations to come.
UNICEF in India
UNICEF supports the Government of India to develop, implement, monitor and report on
evidence-based policy planning and programming for the advancement of all children and
adolescents. India and UNICEF both turned 75 in 2021 year. In India UNICEF have been
active in development and humanitarian response to support the Government of India toward
realizing children’s rights to life, health, safety, and well-being (Table-2).
Table-2: Actions of UNICEF in India in the past 75 years

Year UNICEF partnership
1949 India’s first Penicillin Plant Established in Pimpri
1954 Funded Aarey and Anand milk processing plants to kick start The White Revolution
First DDT plant set up to supply National Malaria Eradication Programme
1966 UNICEF provided drilling rigs to accelerate the government’s efforts to provide safe
drinking water. The emergency programme mounted at that time for Bihar famine
lead, in due course, to a major expansion of the national rural drinking water supply
programme in which UNICEF became the key external partner.
1960 NCERT, UNESCO and UNICEF worked together for reorganisation and expansion
of science teaching in the schools of India.
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1963 Applied Nutrition Programme

1970 The Water Revolution – UNICEF partnered with a government-owned engineering
company, to develop the India Mark II, a well-engineered heavy duty hand pump.
The India Mark II, and the later India Mark III, are now exported to more than 40
countries around the world.
1975 Integrated Child Development Services
1983 Guinea Worm Eradication Programme
1985 National Mission on Immunization
1991 Iodine Deficiency Disorder
1999 Super Cylone of Orissa relief operations
2001 Dular Project was started in selected districts of Bihar and Jharkhand by the
Government with UNICEF support to combat malnutrition, infant mortality and
poor maternal health
2001 Gujarat Earthquake – educational rehabilitation
2004 Tsunami relief
2012 Polio Campaign- Polio cases in India fell from 559 in 2008 to zero cases in 2012
2013 Communication Campaign on Maternal and Child Nutrition
Reduction in MMR
2014 India New-born Action Plan launched
2019 Helping make India open defecation free
10.5. WORLD HEALTH ORGANIZATION (WHO)

The World Health Organization is a specialized agency of the United Nations (UN) that acts
as a coordinating authority on international public health. It was established on 7 April 1948
and its headquarters is in Geneva. WHO promotes technical co-operation for health
programmes to control and eradicate disease and strives to improve the quality of human life.
It monitors disease outbreaks, plans preventive measures, provides cost effective medications
and combats correctively to eradicate infectious disease. WHO works with UNICEF,
UNESCO, World bank and other organizations. The WHO has played a leading role in
several public health achievements, most notably the eradication of smallpox, the near-
eradication of polio, and the development of an Ebola vaccine.
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Its World Health Assembly, the agency's decision-making body, elects and advises an
executive board made up of 34 health specialists. It selects the director-general, sets goals and
priorities, and approves the budget and activities. The current director-general is Tedros
Adhanom Ghebreyesus of Ethiopia.
Objectives
It has a single agenda of improving the health of the people all over the world. Its objectives
are:
 To give worldwide guidance in the field of health.
 To set global standards for health.
 To cooperate with governments in strengthening national health programmes.
 To encourage research and to develop methods to combat disease and make available
their study and technology for all.
Mandate of WHO
The WHO's mandate seeks and includes:
 working worldwide to promote health
 It provides technical assistance to countries, sets international health standards, and
collects data on global health issues.
 A publication, the World Health Report, provides assessments of worldwide health
topics.
 The WHO also serves as a forum for discussions of health issues.
Current mandate of WHO
Its current priorities include communicable diseases, particularly HIV/AIDS, Ebola, COVID-
19, malaria and tuberculosis; non-communicable diseases such as heart disease and cancer;
healthy diet, nutrition, and food security; occupational health; and substance abuse. Strategies
are drawn from time to time. This work is framed by the Comprehensive implementation plan
on maternal, infant, and young child nutrition, adopted by Member States through a World
Health Assembly resolution. According to the 2016–2025 nutrition strategy, WHO uses its
convening power to help –
 set, align and advocate for priorities and policies that move nutrition forward globally;
 develops evidence-informed guidance based on robust scientific and ethical
frameworks;
 supports the adoption of guidance and implementation of effective nutrition actions;
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 monitors and evaluates policy and programme implementation and nutrition

outcomes.
Actions to end malnutrition
These are vital for achieving the diet-related targets of the Global action plan for –
 the prevention and control of noncommunicable diseases 2013–2020,
 the Global strategy for women’s, children’s, and adolescent’s health 2016–2030,
 the report of the Commission on Ending Childhood Obesity (2016),
 and the 2030 Agenda for sustainable development.
 Reduction of salt/sodium intake and elimination of industrially produced trans-fats
from the food supply are identified in GPW13 as part of WHO’s priority actions to
achieve the aims of ensuring healthy lives and promote well-being for all at all ages.
In May 2018, the Health Assembly approved the 13th General Programme of Work
(GPW13).
Health and nutrition related functions
 Feeding special food: WHO has recently increased nutrition work to develop the
cheap foods for babies and infants, which are rich in protein.
 It educates the people about the importance of nutritious foods specifically mothers.
 It conducts medical research programme, which includes human reproduction, drug
evaluation, pollution and to improve sanitary conditions. The WHO is studying the
different types of medical disorders and their treatment. The main function of WHO is
to sponsor the training and research for the medical practitioners of different
countries.
 WHO continuously stresses on the importance of National Health Planning and the
need for each country to make best utilization of the social resources.
 The WHO is always ready to serve in case of major natural calamities like floods,
famines and Quakes.
 WHO acts as a source of information regarding various health problems. A wide
variety of morbidity and mortality statistics relating to health problems are published
by WHO. Food And Agricultural Organization (FAO).
SDGs and WHO
The United Nations Sustainable Development Goals (SDGs) are 17 goals with 169 targets
that all 191 UN Member States have agreed to try to achieve by the year 2030. Health has a
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central place in SDG 3: Ensure healthy lives and promoting well-being for all at all ages,
underpinned by 13 targets that cover a wide spectrum of WHO’s work. Almost all of the
other 16 goals are directly related to health or will contribute to health indirectly. The new
agenda, which builds on the Millennium Development Goals, aims to be relevant to all
countries and focuses on improving equity to meet the needs of women, children and the
poorest, most disadvantaged people.
WHO in India
World Health Organization (WHO) is the United Nations’ specialized agency for Health. It is
an inter-governmental organization and works in collaboration with its member states usually
through the Ministries of Health. The World Health Organization is responsible for providing
leadership on global health matters, shaping the health research agenda, setting norms and
standards, articulating evidence-based policy options, providing technical support to
countries and monitoring and assessing health trends. India became a party to the WHO
Constitution on 12 January 1948. Four current strategic priorities of WHO in India are:
Strategic Priority 1: Accelerate progress on Universal Health Coverage
Strategic Priority 2: Promote health and wellness by addressing determinants of health
Strategic Priority 3: Better protect the population against health emergencies
Strategic Priority 4: Enhance India’s global leadership in health
10.6. THE FOOD AND AGRICULTURAL ORGANIZATION (FAO)

The latest estimates by the Food and Agriculture Organization of the United Nations (FAO)
put the global hunger figure for year 2021 as 768 million people. These estimates imply that,
since 2015, the increase in the number of undernourished people in the world has practically
eroded all progress that had been made during the preceding decade, bringing the world back
to hunger levels that prevailed in 2005, due to this role of this agency becomes more
important. FAO is a specialized agency of the United Nations that leads international efforts
to defeat hunger, serving both developed and developing countries.
Genesis and organization: FAO was founded on 16 October 1945 and is now headquartered
in Rome, Italy, the FAO maintains offices throughout the world. The organization, which has
more than 180 members, is governed by the biennial FAO conference, in which each member
country, as well as the European Union, is represented. The conference elects a 49-member
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Council, which serves as its executive organ. In the late 20th century, the FAO gradually
became more decentralized, with about half its personnel working in field offices.
Objectives:
Its goal is to achieve food security for all and make sure that people have regular access to
enough high-quality food to lead active, healthy lives. Its main objective is to alleviate
poverty and hunger by promoting agricultural development, improved nutrition and the
pursuit of food security-the access of all people at all times to the food they need for an active
and healthy life. Its specific objectives are:
 To secure improvements in the efficiency of production and distribution of all food
and agricultural products.
 To improve the conditions of rural populations.
 To contribute towards an expanding world economy and towards ensuring freedom
from hunger for humanity.
 It gives technical assistance to various Governments.
 To raise the levels of nutrition and standard of living of the population of member
countries.
Functions
A specific priority of the organization is encouraging sustainable agriculture and rural
development, a long-term strategy for the conservation and management of natural resources.
The FAO coordinates the efforts of governments and technical agencies in
 programs for developing agriculture, forestry, fisheries, and land and water resources.
 carry out research; provide technical assistance on projects in individual countries
 FAO is active in land and water development, plant and animal products, forestry,
fisheries, economic and social policy, investment, nutrition
 food standards (CODEX) and commodities and trade, keeping statistics on world
production, trade, and consumption of agricultural commodities. The Codex
Alimentarius Commission (CAC) is an international food standards body established
jointly by the Food and Agriculture organization (FAO) and the World Health
Organization (WHO) in May 1963 with the objective of protecting consumer’s health
and ensuring fair practices in food trade. It also plays a major role in dealing with
food and agricultural emergencies.
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 operates educational programs through seminars and training centres; maintains

information and support services
 publishes a number of periodicals, yearbooks, and research bulletins.
FAO and Sustainable Development Goals (Agenda 30)
The “Agenda 2030” includes 17 goals, 169 targets and 230 indicators, in addition to means of
implementation and the global partnership. The FAO Strategic Framework 2022-31 places
the 2030 Agenda at its centre and will use key SDGs and their indicators to promote focus
and track progress. FAO’s contributions span all SDGs. FAO Strategic Framework 2022-31
embraces the five basic principles that feed into all SDGs – the ‘five Ps’: people, planet,
prosperity, peace, and partnership.
FAO in India
The Food and Agricultural Organization of the United Nations (FAO) has enjoyed valuable
partnership with India since it began operations in 1948. It continues playing a catalytic role
in India’s progress in the areas of crops, livestock, fisheries, food security, and management
of natural resources.
The five Strategic Objectives through their alignment into Regional Initiatives and Regional
Priorities will govern FAO’s support, in addition to the GOI’s priorities and the priorities and
outcomes laid out in the UNSDF.
Priority Area 1- Sustainable and improved agricultural productivity and increased farm
incomes
Priority Area 2- Stronger food and nutrition security systems. Under this priority area, FAO’s
technical assistance will focus on providing technical assistance that drive the “Zero Hunger”
initiative of FAO.
Priority Area 3- Effective natural resource management, community development and
assistance in transboundary cooperation to global public good
Priority Area 4- Enhanced social inclusion, improved skills and employment opportunity in
the agriculture sector
10.7. COOPERATIVE AMERICAN RELIEF EVERYWHERE (CARE)

CARE is one of the world’s largest private humanitarian organizations. Headquartered in
Atlanta, Georgia, committed to help families in poor communities and improve their lives.
Founded in 1945 to provide relief to survivors of World War II, CARE quickly became a
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trusted vehicle for the composition and generosity of millions. CARE international is a body
of ten autonomous member organizations based in Australia, Canada, Denmark, Deutschland,
France, Japan, Norway, Austria, UK and USA.
Objectives
CARE’s mission has evolved over the decades. CARE continues to provide emergency relief
during and after disasters, but the organization today focuses on addressing underlying causes
of poverty. In such areas such as health, HIV/AIDs, natural resources, education and
economic development, CARE works to empower women, because experience has shown
that women’s gains yield dramatic benefits for families and communities.
Components: CARE’s campaigns in the fight against global poverty includes:
 The World Hunger Campaign
 Education (To improve quality and accessibility of basic education)
 HIV/AIDS: (Efforts to reduce spread of disease and to aid the affected one’s).
 Victories over poverty: (Long term solutions to poverty)
 CARE for the child
Different projects undertaken by CARE in India are:
 Integrated Nutrition and Health project (INHP)
 Promoting linkages for urban sustainable Development (PLUS) Project.
 Better Health and Nutrition Project (BHNP)
 Sustainable Tribal Empowerment project (STEP)
 Anaemia Control Project
 Maternal and Infant Survival project (MISP).
 Girls Primary Education (GPE) project.
 Child Survival (CS) project.
 Improving women’s Reproductive Health and Family spacing project.
CARE in India
CARE India is working for over 70 years to bring holistic and sustainable changes. In India
their focus areas are:
Health- Assisting in medical emergencies, reproductive, maternal, neonatal, child and
adolescent healthcare.
Education - Imparting 21st century skills like innovation, problem solving and leadership to
adolescents.
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Livelihood - Developing a professional and entrepreneurial spirit among marginalised women

and girls.
10.8. MID-DAY MEAL SCHEME (PM POSHAN SCHEME)

It is the world’s largest school meal programme aimed to attain the goal of universalization
of primary education. The Ministry of Education (earlier known as the Ministry of Human
Resources and Development) is the authorized body to implement the scheme. It is a
centrally sponsored scheme hence cost is shared between the centre and the states. Tamil
Nadu was the first state to implement the midday meal scheme. Mid-day meal scheme
Provides one meal to all children enrolled in government schools, government-aided schools,
local body schools, special training centres (STC), madrasas and maktabs supported under
Sarva Shiksha Abhiyan (SSA).
Genesis
Mid-Day Meal Scheme was started in India from 15th August 1995 under the name of
‘National Programme of Nutritional Support to Primary Education (NP-NSPE)’.
In October 2007, NP-NSPE was renamed as ‘National Programme of Mid-Day Meal in
Schools,’ which is popularly known as Mid-Day Meal Scheme.
In September 2021, the Mid-Day Meal Scheme was renamed ‘PM POSHAN’ scheme or
Pradhan Mantri Poshan Shakti Nirman. PM POSHAN will extend the hot cooked meals to
students studying in pre-primary levels or Bal Vatikas of government and government-aided
primary schools, in addition to those already covered under the mid-day scheme.
Objectives
The main objectives of the MDM scheme are:
1. To increase the enrolment of the children belonging to disadvantaged sections in the
schools.
2. Leading enrolment to increased attendance in the schools.
3. To retain children studying in classes 1-8.
4. To provide nutritional support to the children of the elementary stage in drought-
affected areas.
Components of Midday Meal Scheme
 In 2001, MDMS became a cooked midday meal scheme under which each eligible
child was provided with a prepared midday meal for a minimum of 200 days:
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 In 2004, MDMS was revised with following provisions:

o Central assistance provided for cooking cost
o Transport subsidy included for all states (Max. of Rs 100 per quintal for
special category states and Rs. 75 per quintal for other states.)
o Management, monitoring and evaluation of the scheme.
o Provision to serve midday meals during summer vacation to the children of
drought-affected areas was also added.
 In 2006, the nutritional norm was revised – Energy intake was increased from 300
calories to 450 calories and protein intake was increased from 8-12 grams to 12
grams.
 It is implemented using one of the three models:
i. Decentralized model – Preparing meals on the site by local cooks, Self-help
groups etc.
ii. Centralized model – In the place of local on-site cooks, under this model, an
external organization cooks food and delivers it to the schools.
iii. International assistance – Various international charity organizations aid
government schools.
 Apart from the calories and food intake, for micronutrients (tablets and deworming
medicines), each child is entitled to receive the amount provided for in the school
health programme of the National Rural Health Mission.
 In September 2021, the Mid-Day Meal Scheme was renamed ‘PM POSHAN’
scheme or Pradhan Mantri Poshan Shakti Nirman. PM POSHAN will extend the hot
cooked meals to students studying in pre-primary levels or Bal Vatikas of government
and government-aided primary schools, in addition to those already covered under the
mid-day scheme.
Pradhan Mantri POSHAN scheme
The revamped scheme has been launched for 5 years, from 2021-22 to 2025-26. It aims to
benefit 11.80 crore children studying in 11.20 lakh schools across India. The scheme is
different from the mid-day meal scheme in the following ways:
1. Apart from providing nutritional meals to schoolchildren, the revamped scheme will
also focus on monitoring the nutritional levels of schoolchildren.
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2. A nutritional expert will be appointed in each school to ensure that the BMI, weight
levels and haemoglobin levels of the students are monitored.
3. In districts with a high prevalence of anaemia, special provisions for nutritional items
would be made.
4. The government is also considering developing nutrition gardens on school campuses
with active participation by students.
5. There could also be cooking competitions held under the scheme to promote ethnic
cuisine and innovative menus based on local ingredients.
MDM Rules, 2015
Midday Meal Rules 2015 are notified on 30th September 2015 under National Food Security
Act (NFSA) 2013.
1. Under the MDM rules, schools are empowered to utilize other funds for midday meals
in case MDM funds get exhausted.
2. On occasions where schools and other required bodies are unable to provide cooked
meals to children; they are to provide food allowances to beneficiaries.
3. Accredited labs to take on the monthly testing of meals on a random basis.
4. Under MDM rules 2015, if children of any school don’t get food for 3 consecutive
school days or 5 days in a month, the concerned state government has to fix the
responsibility on a person or an agency.
Nutrition norms of MDM
Each child from class 1-8 within the age group of six to fourteen years is eligible for a cooked
nutritious meal every day except school holidays; with the following nutritional
requirements:
Calories Intake Primary Upper Primary
Energy 450 calories 700 calories
Protein 12 grams 20 grams
Food Intake Primary Upper Primary
Food Grains 100 grams 150 grams
Pulses 20 grams 30 grams
Vegetable 50 grams 75 grams
Oil and Fats 5 grams 7.5 grams
 The schools procure AGMARK quality items for preparation of midday meals.
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 The meals are to be served in the school premises only.

 Each school should have a hygienic cooking infrastructure to cook midday meals in a
hygienic manner.
 The School Management Committee (SMCs) play a vital role in the monitoring of
MDMS and they are mandated under the right to free and compulsory education act,
2009 or Right to Education Act.
 The headmasters or headmistress are empowered to utilize the school funds on the
account of midday meal fund exhaustion. However, the same has to be reimbursed to
the midday meal fund as soon as the school is credited with the MDM fund.
 The Food and Drugs Administration Department of the State may collect samples to
ensure the nutritive value and quality of the meals.
 Food allowance to be provided to the children whenever cooked meals are not
provided due to unforeseen circumstances.
CHECK YOUR PROGRESS

1. What are the six services provided in the ICDS?
2. List major challenges of ICDS scheme.
3. What are areas and priorities of UNICEF?
4. What are the objectives of WHO?
5. What is the position of WHO with regards to SDGs?
6. Write about FAO in India.
7. Write about the nature of CARE.
8. Write about the genesis of mid-day meal scheme in India.
9. What are the nutrition norms of MDM?
Fill in the blanks

1. Integrated Child Development Service (ICDS) scheme was launched on 2nd October,
______________.
2. ICDS services are provided from ___________ centres.
3. UNICEF is an acronym for _________________.
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4. Food standards CODEX is associated with UN organizations _____________ and

______________.
5. _____________________________ are also referred to as Agenda 30.
6. Headquarters of WHO is in ____________.
7. FAO was founded on ______________ and is now headquartered in _____________.
8. Mid-day meal is now renamed as _______________ scheme.
10.9. SUMMARY
Undernutrition is a result of multiple unfavourable factors. These factors hinder progress by
not realising the true potential of nation’s human resource. Thus, in order to play a powerful
role nation has to focus to overcome undernutrition. To achieve this, policies and programme
are planned formulated and implemented globally and also nationally. The United Nations
Sustainable Development Goals (SDGs) are 17 goals with 169 targets that all 191 UN
member states have agreed to try to achieve by the year 2030.The Government of India
established the NITI Aayog to attain sustainable development goals or the “Agenda 2030”.
National and Global Nutrition Programs such as ICDS, WHO, UNICEF, FAO, CARE and
Midday Meal play an important role in achieving the targets and goals set for the country.
10.10. GLOSSARY
Niti Ayog National Institution for Transforming India. The Planning Commission
which has a legacy of 65 years has been replaced by the NITI Aayog.
DDT Dichlorodiphenyltrichloroethane (DDT) is an insecticide used in
agriculture. The United States banned the use of DDT in 1972. Some
countries outside the United States still use DDT to control of mosquitoes
that spread malaria.
NCERT National Council of Educational Research and Training (NCERT) is an
autonomous organisation set up in 1961 by the Government of India to
assist and advise the Central and State Governments on policies and
programmes for qualitative improvement in school education.
UNESCO United Nations Educational, Scientific and Cultural Organization
(UNESCO) is a specialized agency of the United Nations. It seeks to build
peace through international cooperation in Education, the Sciences and
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Culture.
HIV/AIDS Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially
life-threatening condition caused by the human immunodeficiency virus
Ebola Ebola Virus Disease (EVD) is a rare and deadly disease in people and
nonhuman primates. The viruses that cause EVD are located mainly in
sub-Saharan Africa.
UNSDF United Nations Sustainable Development Framework (UNSDF)
The NITI Aayog is the national counterpart for the UN in India for the
operationalization of the UNSDF.

1. About ICDS- www.icds.gov.in
2. About United Nations agencies- https://www.un.org
3. About Poshan Abhiyan India - https://wcdhry.gov.in › schemes-for-children › poshan-
abhiyan
1. What are the six services provided in the ICDS?
Integrated Child Development Services is Centrally-Sponsored and will provide the
following six services to the beneficiaries:
 Supplementary Nutrition (SNP)
 Health & Nutrition Check-Up
 Immunization
 Non-Formal Education for Children in Pre-School
 Health and Nutrition Education
 Referral services
2. List major challenges of ICDS scheme.
The change recommended by specialists is to build a localized response through
decentralization and flexibility in implementation, besides focusing more sharply on
children under 3 years of age. It is evident, however, from the dimensions of the
burden that much remains to be done, particularly if action has to be accelerated.
Following are the major challenges-
 ICDS scheme is found wanting terms of efficiency and reach.
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 It is vulnerable to malpractice
 Its effectiveness in being able to deliver good nutrition where needed the most
is also questionable.
 The ICDS Scheme is still being implemented as a scheme that provides food
and take-home rations to communities in many states, and its great potential as
an Early Childhood Care and Education initiative has not been explored to the
fullest extent.
3. What are areas and priorities of UNICEF?
 Basic Education and Gender Equality: To promote fund and facilitates for universal
primary education for all and quality education and skill building.
 Vaccines: UNICEF is the world’s largest provider of vaccines.
 Emergencies: Before, during and after humanitarian emergencies, UNICEF is on the
ground, bringing lifesaving help and hope to children and families.
 AIDS and Children: UNICEF also works via advocacy and community outreach to
help governments, communities and families support children orphaned by
HIV/AIDS. UNICEF also support programmes that help prevent mother-to child
transmission of HIV/AIDS.
 Child Protection: Focus areas include raising government awareness of child
protection rights and situation analysis as well as promoting laws that punish child
exploiters working through advocacy and the local offices worldwide. UNICEF helps
strengthen the resources of schools communities and families to care for marginalized
children, including those orphaned by HIV/AIDS.
4. What are the objectives of WHO?
It has a single agenda of improving the health of the people all over the world. Its
objectives are:
 To give worldwide guidance in the field of health.
 To set global standards for health.
 To cooperate with governments in strengthening national health programmes.
 To encourage research and to develop methods to combat disease and make available
their study and technology for all.
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5. What is the position of WHO with regards to SDGs?

The United Nations Sustainable Development Goals (SDGs) are 17 goals with 169
targets that all 191 UN Member States have agreed to try to achieve by the year 2030.
Health has a central place in SDG 3: Ensure healthy lives and promoting well-being
for all at all ages, underpinned by 13 targets that cover a wide spectrum of WHO’s
work. Almost all of the other 16 goals are directly related to health or will contribute
to health indirectly. The new agenda, which builds on the Millennium Development
Goals, aims to be relevant to all countries and focuses on improving equity to meet
the needs of women, children and the poorest, most disadvantaged people.
6. Write about FAO in India.

The Food and Agricultural Organization of the United Nations (FAO) has enjoyed
valuable partnership with India since it began operations in 1948. It continues playing a
catalytic role in India’s progress in the areas of crops, livestock, fisheries, food security,
and management of natural resources.
The five Strategic Objectives through their alignment into Regional Initiatives and
Regional Priorities will govern FAO’s support, in addition to the GOI’s priorities and the
priorities and outcomes laid out in the UNSDF.
a. Priority Area 1- Sustainable and improved agricultural productivity and
increased farm incomes
b. Priority Area 2- Stronger food and nutrition security systems. Under this
priority area, FAO’s technical assistance will focus on providing technical
assistance that drive the “Zero Hunger” initiative of FAO.
c. Priority Area 3- Effective natural resource management, community
development and assistance in transboundary cooperation to global public
good
d. Priority Area 4- Enhanced social inclusion, improved skills and employment
opportunity in the agriculture sector
7. Write about the nature of CARE.
CARE is one of the world’s largest private humanitarian organizations. Headquartered in
Atlanta, Georgia, committed to help families in poor communities and improve their
lives. Founded in 1945 to provide relief to survivors of World War II, CARE quickly
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became a trusted vehicle for the composition and generosity of millions. CARE
international is a body of ten autonomous member organizations based in Australia,
Canada, Denmark, Deutschland, France, Japan, Norway, Austria, UK and USA.
8. Write about the genesis of mid-day meal scheme in India.

Mid-Day Meal Scheme was started in India from 15th August 1995 under the name of
‘National Programme of Nutritional Support to Primary Education (NP-NSPE)’.
In October 2007, NP-NSPE was renamed as ‘National Programme of Mid-Day Meal in
Schools,’ which is popularly known as Mid-Day Meal Scheme.
In September 2021, the Mid-Day Meal Scheme was renamed ‘PM POSHAN’ scheme or
Pradhan Mantri Poshan Shakti Nirman. PM POSHAN will extend the hot cooked meals
to students studying in pre-primary levels or Bal Vatikas of government and government-
aided primary schools, in addition to those already covered under the mid-day scheme.
9. What are the nutrition norms of MDM?

Each child from class 1-8 within the age group of six to fourteen years is eligible for a
cooked nutritious meal every day except school holidays; with the following
nutritional requirements:
Calories Intake Primary Upper Primary
Energy 450 calories 700 calories
Protein 12 grams 20 grams
Food Intake Primary Upper Primary
Food Grains 100 grams 150 grams
Pulses 20 grams 30 grams
Vegetable 50 grams 75 grams
Oil and Fats 5 grams 7.5 grams
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Fill in the blanks

1. Integrated Child Development Service (ICDS) scheme was launched on 2nd October,
1975.
2. ICDS services are provided from Anganwadi centres.
3. UNICEF is an acronym for United Nations Children’s fund.
4. Food standards CODEX is associated with UN organizations FAO and WHO.
5. Sustainable Development Goals are also referred to as Agenda 30.
6. Headquarters of WHO is in Geneva.
7. FAO was founded on 16 October 1945 and is now headquartered in Rome, Italy.
8. Mid-day meal is now renamed as PM POSHAN scheme.
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UNIT-11: NATIONAL NUTRITION SURVEILLANCE SYSTEM
STRUCTURE
11.1. OBJECTIVES
11.2. INTRODUCTION
11.3. NATIONAL NUTRITION SUVEILLANCE SYSTEM
11.4. NATIONAL NUTRITION MONITORING SYSTEM (NNMS)
11.5. FOOD AND NUTRITION SECURITY
11.6. FOOD FOR WORK
11.7. NGO IN COMMUNITY DEVELOPMENT OPERATIONS
11.8. SUMMARY
11.9. GLOSSARY
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11.1. OBJECTIVES
 Understand about the nutrition surveillance system and status in India

 Understand about the concept of food and nutrition security
 Learn about the concept of food for work and its status in India
 Know about NGOs and its role in community development
11.2. INTRODUCTION
Globally, India accounts for the highest proportion of stunted (31 per cent) and wasted
children (51 per cent) and under five deaths (16 per cent). India is also the home to the largest
number of undernourished people in the world (24 per cent of the world population). In order
to achieve the goal of reducing malnutrition it is important to continuously monitor the state
of the vulnerable population, for long-term planning in health and in development,
programme management and timely warning and intervention to prevent critical
deteriorations in food security. Many schemes are currently in operation in India to reach to
the vulnerable section of the population in a targeted manner. Food for work scheme has been
an important way of assuring food for all. This scheme is being continuously streamlined to
ensure that the aid reaches the actual beneficiaries. Besides the governmental programs in
health, nutrition and empowerment, the NGOs play an important role. They are often more
flexible and sensitive to dynamics of the community.
11.3. NATIONAL NUTRITION SUVEILLANCE SYSTEM

Nutrition surveillance system
Nutrition surveillance is a system established to continuously monitor the dietary intake and
nutritional status of a population or selected population groups using a variety of data
collection methods whose ultimate goal is to lead to policy formulation and action planning.
The term ‘nutrition monitoring’ is often used in addition to or interchangeably with ‘nutrition
surveillance’ and is defined as surveillance that is carried out on selected individuals. In this
article, the term nutrition surveillance is used to include all data collection methods that are
described. Three distinct objectives have been defined for surveillance systems, primarily in
relation to problems of malnutrition in developing countries, these are:
(a) For long-term planning in health and in development;
(b) For programme management and evaluation; and
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(c) For timely warning and intervention to prevent critical deteriorations in food
Consumption.
Methods in Nutrition Surveillance

A nutritional surveillance system includes the processes of decision-making and of providing
the necessary information to guide these decisions, for which data collection, flow and
analysis are required. Nutrition surveillance is needed for making decisions affecting
nutrition at various administrative levels, for the purpose of preparing national policies,
planning development programmes relating to public health and nutrition and making timely
warning and intervention programmes.
Data can be gathered by from detailed nutrition assessments, health facility information, rapid
assessments, sentinel site surveillance and intervention data. Information on the wide range of
factors affecting nutrition is also collected from partners in other sectors of health, food
security and water security. Nutrition surveillance needs a comprehensive methodology.
Rapid Assessments are mainly carried out on an ad hoc basis and are useful when nutrition
information is urgently needed and when access to the population of concern is limited by
time or lack of other resources. Anthropometric, dietary and other data are collected during
rapid nutrition assessments which are usually undertaken with partners from food security
and health sectors. For sentinel site surveillance, sites are purposively selected, and nutrition
and related data are collected on a regular basis in areas of heightened concern. Currently,
anthropometric and mortality data on children and adults is combined with information on
diet and coping strategies to allow a close monitoring of populations under stress. Thus,
following main methods are used for surveillance:
 Large scale national surveys
 Repeat small scale surveys
 Clinic-based monitoring
 Sentinel site survey
 School census data
In an emergency setting source of data can be obtained from:
 Rapid nutrition assessments
 Rapid screening based on mid-upper arm circumference
National nutrition surveys
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In India several national surveys to obtain information on health and nutrition indicators are
done periodically. A review of selected nutrition and health surveys in India was published
by Komal Rathi and coworkers in 2018 in Indian Journal of Medical Research. All these are
helpful in formulating policies, interventions and advocacy. The major surveys in India
include the
 National Family Health Surveys (NFHS),
 District Level Household Survey (DLHS),
 Annual Health Survey (AHS),
 National Nutrition Monitoring Bureau (NNMB) Survey,
 Rapid Survey on Children (RSoC)
 Comprehensive National Nutrition Survey (CNNS).
11.4. NATIONAL NUTRITION MONITORING SYSTEM (NNMS)

A nutrition surveillance system has been established by the National Institute of Nutrition
(NIN). The NIN is collaborating with the government on several projects under the Poshan
Abhiyan or National Nutrition Mission, which was launched by the Centre in 2018 to reduce
low-birth weight, stunting and undernutrition, and anaemia among children, adolescent girls
and women.
Objectives
 The system has been established for real-time monitoring and early identification of
people vulnerable to malnutrition.
 Based on the assessment of nutritional problems and analysis of causes or
consequences, and it takes action to mitigate the problems.
Components of National Nutrition Surveillance System
The system has been developed by the institute on the directions of the government and
established in Maharashtra, Meghalaya, Odisha, Kerala, Madhya Pradesh and Telangana.
Following are important aspects of the system:
 The system identifies individuals nutritionally at risk and tracks them.
 The system also identifies the causes of undernutrition among high-risk individuals
and also promotes convergence among primary stakeholders of nutrition for early
initiation of action.
 Under the nutrition surveillance system, nine questionnaires were developed, pre-
tested and finalised after conducting mock surveys in the six states.
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 The finalised paper based on the questionnaires were converted into digital
questionnaires using a special software developed by the NIN-TATA Centre in
Hyderabad.
 These questionnaires were uploaded on tabs, which were distributed to anganwadi
workers. The anganwadi workers have been trained to use the tabs and they submit
reports online to central servers.
 The convergence between the nodal departments of women and child development or
social welfare and with the primary stakeholder departments like health, agriculture,
education, rural works and sanitation was achieved to some extent in the selected
block.
11.5. FOOD AND NUTRITION SECURITY

Food security
World Food Summit in 1996 defined food security for a household as “access by all members
at all times to enough food for an active, healthy life. Food security includes at a minimum:
 The ready availability of nutritionally adequate and safe foods
 Assured ability to acquire acceptable foods in socially acceptable ways (that is,
without resorting to emergency food supplies, scavenging, stealing, or other coping
strategies).
The term “food security” was first used in the international development literature of the
1960s and 1970s, and referred to the ability of a country or region to assure adequate food
supply for its current and projected population. The focus of international and national efforts
was to grow more food and reduce population growth rates to sustainable levels. Food
security was measured by food grain production. In more recent times, though there has been
reduction in severe acute food insecurity, dietary intake in large segments of population does
not meet energy (hunger) and micronutrient (hidden hunger) requirements and consequently
under-nutrition and micronutrient deficiencies are widespread.
Nutrition security
According to the FAO (2009), nutrition security is defined as “physical, economic and social
access to balanced diet, clean drinking water, safe environment, and health care (preventive
and curative) for every individual. Education and awareness are needed to utilise these
services”.
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Factors that affect food and nutrition security
Poverty: Despite the secular decline in extreme poverty in India from 45.9 per cent to 13.4
per cent between 1993 and 2015 (defined at $1.9 per capita per day at the 2011 purchasing
power parity rate (PPP)), India still suffers from a high malnutrition burden (World Bank,
2019). Undernutrition in childhood leads to long-term physical underdevelopment, reduces
the development of learning skills, and, as a consequence, affects productivity and increases
morbidity and mortality. Ensuring access to food is not the same as ensuring optimal
nutritional security. Improving nutritional outcomes also depend upon the availability and
affordability of a nutritious diet.
Agriculture: Inter-linkages between agriculture and nutrition, suggest that an increase in
agricultural productivity and relative reduction in food prices leads to diversification of diet,
particularly towards micronutrient-rich diets such as fruits, vegetables pulses and animal
products. In India, there has been a marked shift in the consumption pattern of people, which
has increased the demand of non-cereal food crops. Over time, the per capita availability of
food grains has declined and the consumption of cereals has remained more or less stagnant
whereas the consumption of nutritious food like livestock products, fruits, vegetables, pulses,
etc., have increased. Moreover, there has been considerable decline in the incidence of
hunger from 4.45 per cent to 1.26 per cent between 1993-94 and 2011-12 (NSSO, 2004-05
and 2011- 12).
Mothers’ educational status, particularly higher education, has the strongest association
with being underweight and stunting. For each year increase in the mother’s higher
educational status, the risk of children dying before one year of age reduces. For infants
belonging to the richer (richest) wealth quintiles, the risk of a child dying before one year of
age decreases.
The wealth index (a proxy for standard of living which includes important factors such as
sanitation and drinking water) also shows a strong association with malnutrition indicators
and the probability of a child suffering from malnutrition decreases in the richer quintiles of
the wealth index. For every one unit increase in the richest wealth quintile, a decrease of
being underweight and of stunting is expected.
The other key factors that have a significant impact on reducing child malnutrition
indicators are the duration of breastfeeding, nutritional and health care interventions such as
antenatal care, taking iron folic acid (IFA) supplements, place of delivery and caste. Unless a
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debate on these key determinants and nutrition sensitive interventions are given precedence,
the target of ending all forms of malnutrition will not be achieved by 2030.
Status of food security in some rapidly developing countries
The experience of three developing countries (Brazil, China, and South Africa) in enhancing
nutritional security and the major public policies and programmes adopted by these countries
to tackle the problem of malnutrition can give insights as to how proceed with ensuring food
security for all. India can draw key lessons from these developing countries to tackle the
challenge of food insecurity and malnutrition. Brazil has transformed its food system and is
investing in agricultural research and development and social protection programmes to
reduce the level of hunger in the country. China, on the other hand, attached great importance
to early childhood development and has formulated a series of plans in this regard. Similarly,
South Africa has introduced various nutritional programmes over the years and explicitly
guaranteed the right to food in its constitution.
Steps to achieve food security for India
 Agricultural policies and programmes to be more “nutrition sensitive” and reinforcing

diet diversification to help focus on both nutrition and child development. There is a
need to implement a cost effective and sustainable approach to develop new nutrient
rich staple food crops through bio-fortification under their Harvest Plus programme.
 Ensuring that food-based safety nets such as PDS provide a more diversified food
basket, including bio-fortified staples. Diverting a part of food subsidy (on wheat and
rice) towards nutritious food can help reduce food and nutritional insecurity.
 Providing liberal scholarships for women’s education, particularly for higher
education in mission mode. Women’s education has a positive multiplier effect on the
nutritional status of children. Efforts are also needed to reduce the dropout rates
among girls in schools, particularly at the secondary and high school level.
 Increasing access to health care and prenatal care facilities along with improving
sanitation and drinking water facilities will have positive outcomes on child and
maternal health.
 A targeted approach is needed to track the gaps in nutritional interventions
programmes, particularly in the clusters of districts where the prevalence of
malnutrition is high.
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11.6. FOOD FOR WORK

The Food for Work Program began in 1977-78. Under this programme, the government-
assisted poor people with tasks such as constructing kutcha roads, clearing debris, and so on,
in exchange for foodgrains. In 2001, the National Food for Work Programme was renamed
after this programme. Our country's poverty problem, as well as unemployment and hunger,
was addressed with the introduction of the food for work programme. focuses on the
country's economic challenges as well as development policies and schemes related to
poverty alleviation.
The National Food for Work Program (NFFWP)
National Food for Work Programme was launched in 14th November 2004 in 150 most
backward districts of the country, identified by the Planning Commission in consultation with
the Ministry of Rural Development and the State Governments.
Goal: The programme operated in the country's most impoverished areas with the goal of
increasing the generation of supplementary wage jobs, in addition to those available under
the Sampoorna Grameen Rozgar Yojana (SGRY), in order to increase the generation of
supplementary wage employment and food security in these districts by creating need-based
economic, social, and community assets. It is open to all rural poor people who need to work
for a living and want to conduct manual, unskilled labour. Food is offered to the states at no
cost.
The Mahatma Gandhi National Rural Employment Guarantee Act 2005 (MGNREGA)
The programme has been incorporated into the National Rural Employment Guarantee Act,
which has taken effect in 200 districts across the country, including 150 NFFWP districts.
Every rural household whose members volunteer to do unskilled manual labour receives a
guarantee of 100 days of work under the Act. MGNREGA is now the most important
employment guarantee scheme in the country. 5.25 crore households have been benefitted in
the current year.
Features of MNREGA: Important features include the following
 Sharing of grains is an important feature. Foodgrains should be supplied at work, or if

the workers all live in the same house, they should be shared. The state government
can distribute food grains through any of its appointed agencies. The States receives
foodgrains at no cost. The states, on the other hand, are responsible for transportation
costs, handling fees, and food grain taxes.
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 Permissible works: Water conservation, dryness management (including forestation

and tree planting), land growth, flood control/protection (including irrigation of
logged water regions), and all-weather rural road connectivity are all factors to
consider.
 Wage: The government establishes a daily minimum salary. Men and women to be
paid equally.
 Monitoring Committee: For each post, a monitoring committee of 5-9 nominated
representatives will be constituted, with at least one SC/ST nominee and a female
representation.
 The Gram Sabha will be responsible for appointing the members of the committee.
The job won't start until the oversight committee is established. Along with the
certificate of completion, the oversight committee is anticipated to submit its report.
 Monitoring: Each district must develop and submit monthly, quarterly, and annual
reports to the state government. Regular inspections are conducted.
11.7. NGO IN COMMUNITY DEVELOPMENT OPERATIONS

Non- governmental organizations (NGOs) can be defined as, “legally constituted
corporations created by natural or legal people that operate independently from any form of
government. The term originated from the United Nations and normally refers to the
organizations that are not a part of the government and are not conventional for-profit
businesses.
In the cases in which NGOs are totally or partially funded by the governments, the NGO
maintains its non-governmental status by excluding government representatives from
membership in the organization.”
The NGOs are essentially heterogeneous, each having its own realm of operation. Their field
of work may vary from taking care of street animals to providing care and rehabilitation of
rescued human trafficking victims. Some of the prominent fields of operation are children,
disabled persons’ education, taking care of the elderly, employment, environment, health,
human rights and women.
History of India’s NGOs
In the first half of the 19th century, the idea of voluntary organisations came into Indian
society for the first time with the initiation of social reform movements. Reform movements
brought in the spirit of devoting life to aid the disadvantaged sections of the society. These
movements recognised the rights of women and untouchables.
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The second half of the 19th century saw the prospering of institutionalised reform movements
like Brahmo Samaj, Arya Samaj, Ramakrishna Mission etc. This led the government to pass
the Societies Registration Act, 1860.
Between 1900 and 1947, successful attempts were made to channelize the voluntary spirit for
the political action and mass mobilisation to gain independence from the oppressive colonial
regime.
The post-independence period saw a large number of voluntary organisations involved in the
process of nation-building. The shift to neoliberal economic and political planning brought
forth the fast-paced growth of voluntary organisations.
Orientation of NGOs
An NGO can have different orientations
Charitable orientation often involves a top-down effort with little participation or input by
beneficiaries. It includes NGOs with activities directed toward meeting the needs of the
disadvantaged people groups.
Service orientation includes NGOs with activities such as the provision of health, family
planning or education services in which the programme is designed by the NGO and people
are expected to participate in its implementation and in receiving the service.
Participatory orientation is characterized by self-help projects where local people are
involved particularly in the implementation of a project by contributing cash, tools, land,
materials, labour, etc.
In the classical community development project, participation begins with the need definition
and continues into the planning and implementation stages.
Empowering orientation aims to help poor people develop a clearer understanding of the
social, political and economic factors affecting their lives, and to strengthen their awareness
of their own potential power to control their lives. There is maximum involvement of the
beneficiaries with NGOs acting as facilitators.
Funding of NGOs
As non-profits, NGOs rely on a variety of sources for funding, including:
 Membership dues
 Private donation
 Sale of goods and services
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 Grants
Despite their independence from government, some NGOs rely significantly on government
funding. Large NGOs may have budgets in the millions or billions of dollars. Individual,
private donors comprise a significant portion of NGO funding. Some of these donations come
from wealthy individuals, such as Ted Turner's $1 billion donation to the United Nations, or
Warren Buffett's 2006 pledge to give 10 million Berkshire-Hathaway class B shares to the
Bill and Melinda Gates Foundation (valued at more than $31 billion in June 2006). Many
NGOs, however, rely on a large number of small donations, rather than a small number of
large donations
Roles of NGOs in the Society
NGOs have brought various social changes for the promotion and development of society.
These organizations work for serving humanity and other good cause. Let’s discuss some of
the major roles played by the various NGOs:
Improving Government performance: It is one of the important works of the NGOs to
ensure that the Government should be responsive and solve the problems of the citizens
thereby making the Government more accountable. NGOs also help in providing suggestions
and their expertise in matters related to policy-making of Government by providing research
teams. Many path-breaking laws in the country like Environmental Protection Act 1986,
Right to Education Act 2009, Right to Information Act 2005.
Acting as a social mediator and facilitating communication: People in India are
influenced a lot by faith, superstitions, belief, and customs. NGOs act as social mediators at
various different levels of society so as to bring the required change in social and behavioral
attitudes prevailing within the social environment. They create awareness among people and
become the voice of the poor and needy person or group. NGOs can work at two different
levels- one is at the upward level whereby NGOs inform the Government about the needs,
abilities, and activities of the people in their local area and at the downward level where
people are informed and educated about the policies and programs of the Government.
Acting as a pressure group: They also act as a pressure group and mobilize public opinion
against various Governmental policies and activities. They also help poor people, Farmers,
STs, SCs etc. in availing quality services by making the Government accountable.
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Building Community Participation: NGOs encourage and facilitate the participation of

disadvantaged communities and help in preserving the culture of diverse communities.
Women Empowerment: The role of NGOs in women empowerment cannot be denied. They
have been constantly fighting against social. Various NGOs like the Agrani foundation,
Eklavya, Sewa, etc. have been trying to achieve gender equality
Mobilising Local Resources: Over utilization of natural resources lead to natural calamities
and environmental threats. NGOs keep an eye on this particular domain so that the
destruction of natural resources does not take place.
Providing Education, Training, and Technical Assistance: NGOs provide education,
training, and technical assistance to the people in need, volunteers, and to other NGOs. Later
on, the trained NGOs provide their services to assist the Government.
Monitoring and evaluation: NGOs monitor and evaluate government policies and activities
that encourage active people’s participation in the developmental process. This also results in
keeping a check on the administrative functions of the Government. 05, etc. have been
formulated with the initiatives of the NGOs.
Some Indian NGOs
The Akshaya Patra Foundation is an NGO in India headquartered in Bengaluru. It strives

to eliminate classroom hunger by implementing the Mid-Day Meal Scheme in the
government schools and government-aided schools. Alongside, Akshaya Patra also aims at
countering malnutrition and supporting the right to education of socio-economically
disadvantaged children. Since 2000, Akshaya Patra has been concerting all its efforts towards
providing fresh and nutritious meals to children on every single school day. They have
partnered with the Government of India and various State Governments, along with the
persistent support from corporates, individual donors they have grown from serving just
1,500 children in 5 schools in 2000 to serving 2 million children. Today, Akshaya Patra is the
world’s largest (not-for-profit run) Mid-Day Meal Programme serving wholesome food every
school day to over 2 million children from 22,367 schools across 14 states & 2 Union
territory of India.
Goonj: A recipient of the “NGO of the Year” award in 2007 at the India NGO Awards, this
NGO aims at solving the clothing problems of the downtrodden. Goonj also provides relief
during Rahat floods in West Bengal, Assam and Bihar.
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Udaan Welfare Foundation: The main aim of this NGO is to help the destitute, the main
area of stress being women, children and senior citizens and also environmental welfare. One
of their main projects is a cancer chemotherapy center.
Helpage India: Established in 1978, the sole aim of this NGO is to provide resources to the
elderly people of our country. Their objective is to make aware the senior citizens of their
rights and protect the rights of the senior citizens of our country so that they can also play a
key role in our society. They also work with the government (both local and national) to
implement policies that will be beneficial to the senior citizens of our country.
Child Rights and You (CRY): Founded in 1979 by Rippan Kapoor, CRY is doing some
great work for child rights. It works at the grassroots level to elevate the lives of thousands of
underprivileged children who are denied of basic rights.
In recent decades, many NGOs in India have aided the government to serve its citizens by
pushing for laws including those on the RTI, food security and rural employment. With
several states not having submitted the data yet, and on the basis of available info, the number
of NGOs in India is estimated to be between 3 to 3.6 million. Still, India’s disproportionate
number of NGOs and their lack of transparency and accountability must be dealt with quickly
to prevent any unfavourable repercussions.
CHECK YOUR PROGRESS

Fill in the blanks
1. ___________ is the term used to describe when dietary intake in large segments of
population does not meet energy and ____________ when micronutrient requirements
are not fulfilled.
2. ____________ is the world’s largest (not-for-profit run) Mid-Day Meal Programme
serving wholesome food every school day to over 2 million children
3. NNMS is also referred to as the ____________Abhiyan.
4. aim of the NGO named ________________ is to provide resources to the elderly
people of our country
Expand the terms
1. MNREGA
2. NFFWP
3. NGO
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4. RSoC
5. NNMS
1. What is nutrition surveillance system?

2. What are the main methods used in nutrition surveillance? In an emergency setting
source of data can be obtained from:
3. Which are the major surveys in India about health and nutrition?
4. Define food security.
5. Define nutrition security.
6. What is the status of food security in some of the rapidly developing countries?
7. Write a brief note about the Mahatma Gandhi National Rural Employment Guarantee
Act 2005 (MGNREGA).
8. Define NGOs.
9. What are the roles of NGOs in the Society?
11.8. SUMMARY
Despite India being self-sufficient in food grain production, it was home to 194.4 million
undernourished people during 2016-18. The prevalence of undernutrition and micronutrient
deficiencies particularly among disadvantaged women and children can be addressed by
integrating the nutritional sensitive programmes with food security, agriculture, poverty
reduction and education to achieve nutritional security. Several Government and Non -
Government programmes and schemes are in operation to ensure food and nutrition security
and community development. MNREGA scheme is a food for work programme benefitting
5.25 crore households. Concurrently the NGOs with there multi-faceted orientation are
supportive in this task.
11.9. GLOSSARY
Surveillance to watch over something or someone , in
order to make corrective decisions
Sentinel an indicator of the presence of disease
Vulnerable population A vulnerable population is a group of
people that requires greater protection than
normal against the potential risks. e.g.
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young children, the elderly, women in

reproductive stage.

1. Komal Rathi, Preeti Kamboj, Priyanka Gupta Bansal and G.S. Toteja, 2018, A review
of selected nutrition & health surveys in India, Indian J Med Res 148, pp 596-611
2. Shyma Jose Ashok Gulati Kriti Khurana,2020, Achieving Nutritional Security in
India: Vision 2030, NABARD Research Study-9, Indian Council for Research on
International Economic Relations (ICRIER).

Fill in the blanks
1. Hunger is the term used to describe when dietary intake in large segments of
population does not meet energy and hidden hunger when micronutrient requirements
are not fulfilled.
2. Akshaya Patra is the world’s largest (not-for-profit run) Mid-Day Meal Programme
serving wholesome food every school day to over 2 million children
3. NNMS is also referred to as the Poshan Abhiyan.
4. aim of the NGO named Helpage India is to provide resources to the elderly people of
our country
Expand the terms
1. MNREGA Mahatma Gandhi National Rural Employment Guarantee Act

2. NFFWP The National Food for Work Program
3. NGO Non Governmental organization
4. RSoC Rapid Survey on Children
5. NNMS National nutrition monitoring system
1. What is nutrition surveillance system?

Nutrition surveillance is a system established to continuously monitor the dietary
intake and nutritional status of a population or selected population groups using a
variety of data collection methods whose ultimate goal is to lead to policy formulation
and action planning.
2. What are the main methods used in nutrition surveillance?
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Following main methods are used for surveillance:

 Large scale national surveys
 Repeat small scale surveys
 Clinic-based monitoring
 Sentinel site survey
 School census data
In an emergency setting source of data can be obtained from:
 Rapid nutrition assessments
 Rapid screening based on mid-upper arm circumference
3. Which are the major surveys in India about health and nutrition?
The major surveys in India include the
a. National Family Health Surveys (NFHS),
b. District Level Household Survey (DLHS),
c. Annual Health Survey (AHS),
d. National Nutrition Monitoring Bureau (NNMB) Survey,
e. Rapid Survey on Children (RSoC)
f. Comprehensive National Nutrition Survey (CNNS).
4. Define food security.
World Food Summit in 1996 defined food security for a household as “access by all
members at all times to enough food for an active, healthy life. Food security includes
at a minimum:
 The ready availability of nutritionally adequate and safe foods
 Assured ability to acquire acceptable foods in socially acceptable ways (that is,
without resorting to emergency food supplies, scavenging, stealing, or other coping
strategies).
5. Define nutrition security.
6. According to the FAO (2009), nutrition security is defined as “physical, economic and
social access to balanced diet, clean drinking water, safe environment, and health care
(preventive and curative) for every individual. Education and awareness are needed to
utilise these services”.
7. What is the status of food security in some of the rapidly developing countries?
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The experience of three developing countries (Brazil, China, and South Africa) in
enhancing nutritional security and the major public policies and programmes adopted
by these countries to tackle the problem of malnutrition can give insights as to how
proceed with ensuring food security for all. India can draw key lessons from these
developing countries to tackle the challenge of food insecurity and malnutrition.
Brazil has transformed its food system and is investing in agricultural research and
development and social protection programmes to reduce the level of hunger in the
country. China, on the other hand, attached great importance to early childhood
development and has formulated a series of plans in this regard. Similarly, South
Africa has introduced various nutritional programmes over the years and explicitly
guaranteed the right to food in its constitution.
8. Write a brief note about the Mahatma Gandhi National Rural Employment Guarantee
Act 2005 (MGNREGA).
The programme has been incorporated into the National Rural Employment
Guarantee Act, which has taken effect in 200 districts across the country, including
150 NFFWP districts. Every rural household whose members volunteer to do
unskilled manual labour receives a guarantee of 100 days of work under the Act.
MGNREGA is now the most important employment guarantee scheme in the country.
5.25 crore households have been benefitted in the current year.
9. Define NGOs.
Non- governmental organizations (NGOs) can be defined as, “legally constituted
corporations created by natural or legal people that operate independently from any
form of government. The term originated from the United Nations and normally refers
to the organizations that are not a part of the government and are not conventional for-
profit businesses.
10. What are the roles of NGOs in the Society?
NGOs have brought various social changes for the promotion and development of
society. These organizations work for serving humanity and other good cause. Some of
the major roles played by the various NGOs:
 Improving Government performance

 Acting as a social mediator and facilitating communication
 Acting as a pressure group
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 Building Community Participation

 Women Empowerment
 Mobilising Local Resources
 Providing Education, Training, and Technical Assistance
 Monitoring and evaluation of government policies and activities that encourage active
people’s participation in the developmental process.
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UNIT-12: CONCEPT AND MEANING OF FOOD QUALITY AND FOOD SAFETY
STRUCTURE
12.1. OBJECTIVE
12.2. INTRODUCTION
12.3. CONCEPT AND MEANING OF FOOD QUALITY AND FOOD SAFETY
12.4. FOOD ADULTERATION AND FOOD HAZARD
12.5. NATURAL TOXINS
12.6. FOOD LAWS AND STANDARDS
12.7. SUMMARY
12.8. GLOSSARY
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12.1. OBJECTIVE
 Understand about the concept of food safety and quality

 Understand about the food hazards and adulteration
 Know about natural food toxins
 Learn about the food laws and their scope in India and globally
12.2. INTRODUCTION
Ensuring food safety and quality is essential in the entire chain of food production starting
with primary food production at the level of farmers to secondary food processing level such
as canning, freezing, drying and brewing to food distribution, both at domestic and global and
down to domestic food preparation level. Thus, the food safety includes a farm to plate
approach. During recent years, newer challenges such as globalization of trade in food,
urbanization, changes in life style, international travel, environmental pollution, deliberate
adulteration and natural and man-made disasters have arisen which need to be addressed to
help ensure food safety and quality. Greater numbers of people eat their meals outside their
homes. The boom in food service establishments is not matched by effective food safety
education and control. Unhygienic preparation of food provides plenty of opportunity for
contamination, growth or survival of food borne pathogens. Building consumer confidence in
the safety and quality of the food supply is an important requirement for the whole food
supply chain.
12.3. CONCEPT AND MEANING OF FOOD QUALITY AND FOOD SAFETY

Importance of food safety has gained more importance in modern society due to expansion of
trade networks when food began to be shipped long distances. Today, food safety is a global
concern due to rapid growth in international trade of food products and consumers are
exposed to a greater variety of food products. Such trade can introduce new or unfamiliar
food safety risks, and the chain of responsibility has become longer and more complex.
Definitions
Food Quality: According to the Food and Agriculture Organization of the United Nations
(FAO), food quality is “a complex characteristic of food that determines its value or
acceptability to consumers”. A food’s nutritional value contributes to its perceived quality, as
do its organoleptic and functional properties. Another element of quality is a food’s safety.
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Food safety: According to FAO a safe food is one that is free of any substances that might
compromise a person’s health. WHO also has a similar definition, as per them-food Safety
can be defined as the assurance that food will not cause harm to the consumer when it is
prepared and or eaten according to its intended use.
The concept of “safe food” differs according to the stakeholder. Consumers, special interest
groups, regulators, industry, and academia will have their unique descriptions based on their
perspectives. Safe food is a composite of all of the views and descriptions held by consumers,
special interest groups, academicians, regulatory authorities, and industry. Safe food, if
properly handled at all steps of production through consumption, is reliably unlikely to cause
illness or injury.
Food management systems: are important aspects of keeping foods safe for the populations.
In order to keep pace with the lengthening food supply chain, food safety management
systems continuously need to be improved, so as to ensure that people are provided with safe
food products. Concepts of food safety and food quality are now global and universal.
Examples of food safety management systems include the Hazard Analysis Critical Control
Points (HACCP), Good Manufacturing Practice (GMP) and Hood Hygiene Practice (GHP).
Such systems have been implemented in various countries in recent years.
FAO’s work on food safety and quality
With an estimated 600 million cases of foodborne illnesses annually, unsafe food is a threat
to human health and economies globally. Therefore, ensuring food safety is a public health
priority and an essential step to achieving food security. Effective food safety and quality
control systems are key not only to safeguarding the health and well-being of people, but also
to fostering economic development and improving livelihoods by promoting access to
domestic, regional and international markets.
The Food Safety and Quality unit supports the strengthening of systems of food safety and
quality control at national, regional and international levels. This involves:
 Strengthening national food control regulatory capacities and global trade facilitation
by providing leadership in supporting countries in the assessment and progressive
development of food control systems, including food safety policy and food control
regulatory framework.
 Supporting development of institutional and individual capacities for food control and
food safety management, including the management of food safety emergencies.
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 Supporting science-based food safety governance and decisions by providing sound

scientific advice (through the JECFA and JEMRA expert bodies) to underpin food
safety standards at national, regional and international levels.
 Enhancing food safety management along food chains to prevent diseases and trade
disruptions by supporting developing countries to apply risk-based food safety
management along food chains that are appropriate for national and local production
systems and in compliance with Codex texts.
 Providing food safety platforms, databases and mechanisms which support
networking, dialogue and global access to information and facilitating effective
communication internationally on key food safety issues.
 Developing food safety intelligence and foresight by becoming a major actor in the
collection, analysis and communication of food chain intelligence.
 Evaluating new technologies to improve food safety and protect public health.
FAO is a recognized leader in the development of global food safety initiatives and
translating these into country level action. The foundations for this approach are based on
science. FAO's Food Safety and Quality Unit often works in partnership with national and
international bodies and organizations where such partnerships are mutually beneficial and
where there is a compatibility of mandate and guiding principles.
12.4. FOOD ADULTERATION AND FOOD HAZARD
Food Adulteration
Food adulteration includes not only intentional addition or substitution or abstraction of

substances which adversely affect the nature, substances and quality of foods, but also their
incidental contamination during the period of growth, harvesting, storage, processing,
transport and distribution. A food adulterant may be defined as any material which is added
to food or any substance which adversely affects the nature, substance and quality of the
food.
There are many adulterants which might prove to be a hazard to our health especially if
consumed over a long period of time. Chemicals like urea, sodium carbonate, sodium
hydroxide, formaldehyde and hydrogen peroxide added to increased shelf life of milk can be
harmful when ingested. They can damage the intestinal lining irritating it. Un- permitted food
additives or permitted food additives added in excess; both can cause serious damage of
health. Whether they are flavouring, colourings, preservatives, antioxidants etc. They are all
chemicals which are safe only if eaten in very small quantities. The use of certain colours has
been banned as they are well known or their toxicity in experimental animals. Non- permitted
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colours like auramine, Rhodamine B, Sudan red, Malachite green, Orange II lead to
retardation of growth and affects the proper functioning of vital organs like liver, kidneys,
heart spleen, lungs, bones and the immune systems. The commonly used Metanil yellow
could be injurious to the stomach, ileum, rectum, liver, kidney, ovary and testis. All he non-
permitted colours can also bring about changes in genes, most having been identified as
potential cancer- causing agents. Toxicity of permitted colours is also well demonstrated as
allergic response to these colours e.g., Tartrazine.
Economic impact of adulteration is also significant and involve value of food rendered unfit
for consumption and cost of treating people who have fallen sick, been disabled or the heavy
cost of lives lost. When exported adulterated foods have to be often recalled, cases are filed
resulting in loss of credibility in the international market.
Types of adulteration
Adulteration can occur in several ways:
 If any inferior or cheap substance has been substituted wholly or in part for the article
e.g., starch powder has been mixed in milk powder.
 If the article contains, or processing has produced in it, injurious ingredients, for
instance during the process of hydrogenating oil to prepare vanaspati, nickel is used as
a catalyst. If not properly removed, this metal can prove to be hazard.
 If any constituent of the article has been wholly or in part abstracted e.g., natural
flavours or essential oils have been removed from spices before selling them.
 If the article has been prepared packed or kept under unsanitary conditions or it has
become contaminated or injurious to health
 If the article has any filth, putrid rotten decomposed or diseased animal or vegetable
substances or is insect infected or is otherwise unfit for human consumption
 If the article is obtained from a diseased animal
 If the article contains any poisonous or other ingredient which render it injurious to
health
 If the container of the articles composed of poisonous or deleterious substances which
render its content injurious to health.
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 If it contains un-permitted colours or prohibited preservatives or if the amount of the

prescribed colouring matter is not within the prescribe limits.
 If it does not satisfy the prescribed standards laid down by the authorities for
permitted level of pesticides
Commonly adulterated foods
Usually popular and expensive foods or foods which are in a powder, minced or paste form
are more likely to be adulterated. Foods sold loose is also more likely to be adulterated as
compared to packaged foods. Foods commonly adulterated include - food grains and their
products, edible oils and fats, spices, both whole and ground, ghee and milk powder, coffee
and tea, sugar and honey, beverages and items like confectionary, jams, sauces, ice creams
and prepared foods items. Foods gets adulterated at different stages of manufacturing and
marketing.
Common adulterants and their detection
The following table gives a compilation of the types of adulterants (excluding microbial
contaminants) detected in different food items.
Table 1: Types of adulterants
Food items Adulterant detected

Milk Antibiotics residues, formalin, boric acid, pesticide
residues, neutralizers like sodium bicarbonate, urea, water,
sugar, starch, foreign fat.
Milk powder Pesticide residues, sugar, starch, fat, deficiency, excessive
moisture.
Ghee and Vanaspati Extraneous colour, animal body fat, hydrogenated vegetable
oils, excessive moisture.
Edible oils Castor oils, mineral oil, argemone oil, triorthocresyl
phosphate, oil soluble colours, aflatoxin, pesticide residues,
and cheaper vegetable oils.
Spices Non- permitted colours, mineral oil coating, husk starch,
foreign seeds/ resins, extraneous matter, exhausted spices.
Non-alcoholic beverages Saccharin, dulcin, brominated vegetable oil, non-permitted
colours, and excessive permitted colours.
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Confectionary, sweets and Non- permitted colours, aluminium foil, permitted colour
savouries more than prescribed limit.
Coffee Chicory, date or tamarind seeds, artificial colour.
Tea Colour, iron filings, foreign leaves, exhausted leaves.
Pulses and their products Foreign pulses like lathyrus sativus, vicia sativa, lens
like besan or kadale hittu esculenta (these are considered inferior), artificial colours,
(gram flour) talc, foreign starch, extraneous matter
Cereals and their products Fungal infestation, pesticide residues, sand, dirt, foreign
like maida, suji, flour starch, powdered chalk, iron filings.
Source: FSSAI, 2010
Although simple forms of adulteration like addition of water to milk and coloured starch to
turmeric are still prevalent, newer forms and types of adulteration are emerging such as
pesticides residues, coating insect- infested dry ginger with ultramarine blue to cover holes
and other damage; urea in puffed rice to improve texture; injecting colour into poor quality
fruits, vegetables.
Adulterants can be detected by simple visual tests, physical tests and chemical tests (Table 2).
Table 2: Simple methods for detection of common adulterants
Food Adulterant Method of detection

Visual tests
Pulses, whole and Kesari dal Kesari dal is wedge shaped, with a slant on one side
split and a square face on the other side.
Mustard seeds Argemone seeds Argemone seeds have a rough surface with a little tail
at one end. Mustard seeds are smooth. Upon
pressing, mustard seeds are yellow inside while
argemone seeds are white.
Black pepper Papaya seeds Papaya seeds are comparatively shrunken, oval, and
greenish brown to brownish black in color.
Physical tests
Milk Water Measures the specific gravity with a lactometer by
immersing it in milk kept in a deep vessel. The
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normal value lies between 1.028-1.032. lower value

indicates added water. But this is not a fool proof
method as in addition to water, sugar, urea may have
been added to the milk to increase its specific
gravity.
Tea leaves, suji Iron fillings Easily separated by passing a magnet over surface of
food.
Honey Sugar solution lighted. If water is present, it will not allow the honey
to burn. Even if it does, a crackling sound is
produced. (The test is for water which is there in the
sugar solution added as an adulterant to honey).
Coffee Chicory Sprinkle coffee powder on the surface of water in a
glass. Coffee floats while chicory starts sinking
leaving a trail of color, due to a large amount of
caramel.
Tea Artificial color Put the tea leaves on a moistened blotting paper.
Artificially dyed tea will impart color to the
moistened blotting paper immediately.
Milk Developed acidity Place a test tube containing 5 ml of the milk sample
in a boiling water bath and hold for about 5 minutes.
Remove the tube and rotate in an almost horizontal
position. The film of milk on the side of the test tube
is examined for any precipitated particles. Formation
of clots is indicative of developed acidity in the milk
due to microbial spoilage. Such milk is unsuitable for
consumption.
Chemical tests
Milk, milk Starch Mix sample in the test tube with water, add a few
products, drops of iodine solution. Blue color indicates the
powdered spices presence of starch.
Milk, milk Neutralizers like To about 5 ml of milk in a test tube, add 5 ml of
powder carbonates alcohol and a few drops of rosalic acid solution and
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mix the contents of the test tube. A rose red color is

obtained in the presence of a carbonate whereas pure
milk shows only a brownish colouration.
Ghee, butter Margarine or In one tea spoon-full of completely melted sample,
vanaspati add 5 ml concentrated hydrochloric acid. Shake for 5
minutes; add a pinch of sugar or furfural. Appearance
of pink color in the acid layer indicates added
vanaspati.
Sweetmeats, ice Metanil yellow Extract color with lukewarm water from food
cream and samples and add a few drops of concentrated
beverages, hydrochloric acid. A magenta color indicates the
selarice, pulses, presence of metanil yellow.
spices
Pulses, whole and Kesari dal Put a sample in dilute hydrochloric acid. Pink color
split, besan develops indicating the presence of kesari dal.
Silver foil Aluminium foil To metal foil add 2 drops of concentrated nitric acid
in a test tube. The silver foil will completely dissolve
whereas the aluminium foil remains undissolved.
Source: FSSAI, 2010
Food Hazard
Food hazards are the factors, which are the biggest threat to food safety. A hazard is defined
as: a biological, chemical, or physical agent in a food, or condition of a food, with the
potential to cause an adverse health effect. Hazards are classified into three categories -
physical, chemical and biological hazards.
A. Biological hazards: Biological hazards include bacterial, fungal, viral and parasitic
(protozoa and worms) organisms and/or their toxins. There are many microorganisms
which are pathogenic in humans but relatively few are associated with foods and
those are, are termed food-borne pathogens. There are two types of food-borne
disease from microbial pathogens: infections and intoxications. Infections result from
ingestion of live pathogenic organisms which multiply within the body and produce
disease. Intoxications occur when toxins produced by pathogens are consumed.
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Intoxications can occur even if no viable microorganisms are ingested. This often
occurs when foods are stored under conditions which allow the pathogens to grow and
produce toxin. Subsequent processing of the food may destroy the microorganisms
but not the toxin. The microorganisms may give a mild to severe level of adverse
reaction in the host.
Hazardous microorganisms and parasites grouped on the basis of risk severity

I. Severe Hazards
Clostridium botulinum types A, B, E and F – causes botulinism
Shigella dysenteriae - causes dysentry
Salmonella typhi; paratyphi A, B - causes typhoid
Vibrio cholera 01 - causes cholera
II. Moderate Hazards: Potentially Extensive Spread
Listeria monocytogenes
Salmonella spp.
rotavirus
III. Mild Hazards: Limited Spread
Campylobacter jejuni
Clostridium perfringens
Staphylococcus aureus
B. Chemical hazards are in two categories: naturally occurring poisons and chemicals
or deleterious substances. The first group covers natural constituents of foods that are
not the result of environmental, agricultural, industrial or other contamination.
Examples are aflatoxins and shellfish poisons. The second group covers poisonous
chemicals or deleterious substances which are intentionally or unintentionally added
to foods at some point in the food chain. This group of chemicals can include
pesticides and fungicides and well as lubricants and cleaners.
C. Physical hazard is any physical material not normally found in food which causes
illness or injury. Physical hazards include glass, wood, stones and metal which may
cause illness and injury (Table 3)
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Table 3: Common physical hazards in the food chain

Material Injury potential Sources
Glass Cuts, bleeding; may require surgery to find Bottles, jars, light fixtures,
or remove utensils, gauge covers
Wood Cuts, infections, choking; may require Fields, pallets, boxes,
surgery to remove buildings
Stones Choking, broken teeth Fields, buildings
Metal Cuts, infection; may require surgery to Machinery, fields, wire,
remove employees
Insects & Illness, trauma, choking Fields, plant post process
filth entry
Insulation Choking; long term if asbestos Building materials
Bone Choking, trauma Fields, improper plant
processing
Plastic Choking, cuts, infection; may require Fields, plant packaging
surgery to remove materials, pallets, employees
Personal Choking, cuts, broken teeth; may require Employees
effects surgery
Food contamination
Food contamination refers to the presence of harmful chemicals and microorganisms in food
which can cause consumer illness. A food contaminant has been defined as any substance
not intentionally added to food, which is present in such food as a result of the production,
manufacture, processing, preparation, treatment, packing, transport or storage of such food as
a result of environmental contamination. It is important to protect food from risk of
contamination to prevent food poisoning and the entry of foreign objects. There are three
main ways in which food can become contaminated: (i) Microbial Contamination; (ii)
Physical Contamination; (iii) Chemical Contamination.
Physical contaminant → Physical Hazard

Chemical contaminant → Chemical Hazard →UNSAFE FOOD
Biological contaminant → Biological Hazard
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Relation between contaminants and hazards
Control measures for biological hazards

The most worrisome and difficult to control are the biological hazards. Hygiene and
sanitation pertain mainly to this hazard.
The word hygiene means using sanitary principles to maintain health.
Personal hygiene refers to the cleanliness of a person's body and clothes. Food workers need
to be healthy and clean to prepare safe food. Personal hygiene in food handlers can prevent
several diseases.
Sanitation is the effective use of tools and actions that keep our environment healthy. These
include latrines or toilets to manage waste, food preparation, washing stations, effective
drainage and other such mechanisms. Hygiene is a set of personal practices that contribute to
good health.
Hygiene is used in a personal context while sanitation is used to refer in a public context.
Following are the control measures of hygienic food handling:
Barriers: using barriers to separate the food from anything that could contaminate it at all
stages of production. Barriers include disposable gloves, hairnets, mouth guards, sneeze
guards, lids, and food wraps.
Hiring employees: Careful hiring of employees help companies to keep a good image and
meet regulations. Over 50% of people carry Staphylococcus aureus in their mouths and nasal
passages. Many carriers of disease do not have obvious symptoms. Many employers do not
screen potential employees at entry as it is expensive and workers can be infected after they
are hired.
Personal Hygiene Rules: Food organizations should have clear and strict personal hygiene
rules. The rules should be clearly posted on the wall or spelled out in booklets given to each
employee. The policies should cover personal cleanliness, clothing, good food-handling
practices, and use of tobacco. Employees should maintain personal hygiene in the following
ways. They should:
I. Maintain good physical health through good nutrition, enough rest, and physical
cleanliness.
II. Report illness to their employer before working with food so that assignments can be
adjusted to protect food from being contaminated.
a) Should not have respiratory, gastrointestinal, or other diseases
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b) Should report injuries—including cuts, burns, boils, and skin problems—to their
employer
c) Should report respiratory illnesses (e.g., colds, influenza, sinus infections, and
bronchitis) and intestinal illnesses, such as diarrhea, to their employer
III. Practice good hygiene so that they do not contaminate food.
IV. Wash their hands during their work shift after using the toilet; after handling garbage
or other dirty items; after handling uncooked meats, egg products, or dairy products;
after handling money; after smoking; after coughing and sneezing; and when leaving
or returning to food production/service areas.
V. Maintain personal cleanliness through daily bathing, washing hair at least twice a
week, cleaning fingernails daily, use of a hat or hairnet while handling food, and
wearing clean underclothing and uniforms.
VI. Not touch foodservice equipment and utensils with their hands, and use disposable
gloves if they have to touch food (other than dough).
VII. Break such habits as scratching their heads or touching other parts of their body
VIII. Cover their mouths and noses when they cough or sneeze
IX. Wash their hands after using the toilet, blowing their nose, smoking, handling
anything dirty, and handling money.
X. Keep their hands out of food. Food should not be tasted using a hand and should not
be eaten in food production areas
XI. Not use utensils that touch their mouths to handle food
XII. Use disposable gloves to handle food
XIII. Not smoke or chew tobacco in food production and food preparation areas and should
wash their hands after smoking.
Sanitizing methods
Handwashing: Improper handwashing causes about 25% of foodborne illnesses. Hand
washing with soap and water removes bacteria. Rubbing the hands together or using a scrub
brush removes more bacteria than quick hand washing. Antimicrobial agents remove more
bacteria than ordinary hand soap, but employees need to use antimicrobial hand soap
throughout the day for it to be fully effective. The antimicrobial agent needs to be in contact
with the hands for more than 5 seconds to have an effect on the number of microbes.
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Heat: Heat is an inefficient sanitizer because it takes so much energy. The efficiency of heat
depends on the humidity, the temperature required, and the length of time it takes to destroy
microbes at that temperature. Heat destroys microorganisms if the temperature is high enough
for long enough and if the design of the equipment or plant allows the heat to reach every
area.
Hot Water: Immersing small components (such as knives, small parts, eating utensils, and
small containers) into water heated to 82°C (18O°F) or higher are another way to sterilize
using heat. If equipment or surfaces are sterilized at a lower temperature, they must be kept at
that temperature for longer. If they will be sterilized for a shorter amount of time, the
temperature must be higher. This is known as a "time-temperature relationship".
Examples of times and temperatures used for sterilization are 15 minutes of heat at 85°C
(185°F), or 20 minutes at 82°C (18O°F). The volume of water and how fast it is flowing can
determine how long it takes for the item being sterilized to reach the right temperature. Hot
water is readily available and is not toxic.
Radiation: Radiation in the form of ultraviolet light or high-energy cathode or gamma rays
destroys microorganisms. For example, hospitals and homes may use ultraviolet light from
low-pressure mercury vapor lamps to destroy microorganisms.
Chemicals: Food-processing and foodservice operations use various chemical sanitizers for
different areas and types of equipment. More-concentrated sanitizers generally act more
quickly and effectively. Sanitation staff needs to know and understand how each chemical
sanitizer works so that they can choose the best sanitizer for each job. Most chemical
sanitizers are liquids, but some chlorine compounds and ozone are gases. It is important not
to expose workers to a toxic chemical if a gas sanitizer is used. Chemical sanitizers do not get
right into cracks, crevices, pockets, and mineral soils, and so may not completely destroy
microbes in these places. It is also very important to make sure that the chemicals are safe to
mix together to avoid dangerous reactions. The effectiveness of chemical sanitizers depends
on:
 Exposure time: Colonies of microbes die in a logarithmic pattern. This means that if
90% of the microbes die in 10 minutes, 90% of the remaining microbes die in the next
10 minutes, and so on. Therefore, in this example, only 1% of the original number of
microbes is still alive after 20 minutes. When more microbes are present, sanitation
staff needs to use a longer exposure time to reduce the population to a low-enough
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level. The age of the colony and the type of microorganism affect how quickly they
die.
 Temperature: Chemical sanitizers kill microorganisms more quickly at higher
temperatures.
 Concentration: More-concentrated sanitizers kill microorganisms more quickly.
 pH: Even small changes in acidity or alkalinity can affect the activity of sanitizers.
Chlorine and iodine compounds are generally less effective when the pH is higher
(more alkaline).
 Cleanliness: If equipment and surfaces are not thoroughly clean, soil (dirt) can react
with hypochlorites, other chlorine compounds, iodine compounds, and other sanitizers.
This reaction neutralizes the sanitizer so that it does not work properly.
 Water hardness: Hard water makes sanitizers less effective.
 Bacterial attachment: Some bacteria attach to solid surfaces. This makes the bacteria
more resistant to chlorine.
12.5. NATURAL TOXINS
According to WHO, natural toxins are toxic compounds that are naturally produced by living
organisms. These toxins are not harmful to the organisms themselves but they may be toxic to
other creatures, including humans, when eaten. These chemical compounds have diverse
structures and differ in biological function and toxicity.
Some toxins are produced by plants as a natural defence mechanism against predators, insects
or microorganisms, or as consequence of infestation with microorganisms, such as mould, in
response to climate stress (such as drought or extreme humidity).
Other sources of natural toxins are microscopic algae and plankton in oceans or sometimes in
lakes that produce chemical compounds that are toxic to humans but not to fish or shellfish
that eat these toxin-producing organisms. When people eat fish or shellfish that contain these
toxins, illness can rapidly follow.
Common food toxins
Some of the most commonly found natural toxins that can pose a risk to our health are
described below.
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Aquatic biotoxins: Toxins formed by algae in the ocean and fresh water are called algal
toxins. Shellfish such as mussels, scallops and oysters are more likely to contain these toxins
than fish. Algal toxins can cause diarrhoea, vomiting, tingling, paralysis and other effects in
humans, other mammals or fish. The algal toxins can be retained in shellfish and fish or
contaminate drinking water. They have no taste or smell, and are not eliminated by cooking
or freezing.
Cyanogenic glycosides: Cyanogenic glycosides are phytotoxins (toxic chemicals produced

by plants) which occur in at least 2000 plant species, of which a number of species are used
as food in some areas of the world. Cassava, sorghum, stone fruits, bamboo roots and
almonds are especially important foods containing cyanogenic glycosides. The potential
toxicity of a cyanogenic plant depends primarily on the potential that its consumption will
produce a concentration of cyanide that is toxic to exposed humans. In humans, the clinical
signs of acute cyanide intoxication can include: rapid respiration, drop in blood pressure,
dizziness, headache, stomach pains, vomiting, diarrhoea, mental confusion, cyanosis with
twitching and convulsions followed by terminal coma. Death due to cyanide poisoning can
occur when the cyanide level exceeds the limit an individual is able to detoxify.
Furocoumarins: These toxins are present in many plants such as parsnips (closely related to
carrots and parsley), celery roots, citrus plants (lemon, lime, grapefruit, bergamot) and some
medicinal plants. Furocoumarins are stress toxins and are released in response to stress, such
as physical damage to the plant. Some of these toxins can cause gastrointestinal problems in
susceptible people. Furocoumarins are phototoxic, they can cause severe skin reactions under
sunlight (UVA exposure). While mainly occurring after dermal exposure, such reactions have
also been reported after consumption of large quantities of certain vegetables containing high
levels of furocoumarins.
Mycotoxins: Mycotoxins are naturally occurring toxic compounds produced by certain types
of moulds. Moulds that can produce mycotoxins grow on numerous foodstuffs such as
cereals, dried fruits, nuts and spices. Mould growth can occur before harvest or after harvest,
during storage, on/in the food itself often under warm, damp and humid conditions.
Most mycotoxins are chemically stable and survive food processing. The effects of food-
borne mycotoxins can be acute with symptoms of severe illness and even death appearing
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quickly after consumption of highly contaminated food products. Long term effects on health
of chronic mycotoxin exposure include the induction of cancers and immune deficiency.
Solanines and Chaconine: All solanacea plants, which include tomatoes, potatoes, and
eggplants, contain natural toxins called solanines and chaconine (which are glycoalkaloids).
While levels are generally low, higher concentrations are found in potato sprouts and bitter-
tasting peel and green parts, as well as in green tomatoes. The plants produce the toxins in
response to stresses like bruising, UV light, microorganisms and attacks from insect pests and
herbivores. To reduce the production of solanines and chaconine it is important to store
potatoes in a dark, cool and dry place, and not to eat green or sprouting parts.
Toxic constituents in pulses
Some pulses contain chemical constituents that have toxic properties.
Protease inhibitors (Trypsin inhibitors): Proteolytic enzymes, or proteases, catalyze the

hydrolytic cleavage of specific peptide bonds in their target proteins. They are widespread in
the plant kingdom and form less active or fully inactive complexes with their cognate
enzymes. Protease inhibitors common in pulses include trypsin inhibitors. Protease inhibitors
can comprise as much as 6% of a legume’s total protein content. The extent to which their
activity is destroyed by heat is a function of temperature, heating duration, particle size, and
moisture conditions. Relatively little protease inhibitor remains in properly processed pulses.
Soaking and cooking different beans at 95°C in water (1:5 seed:water) in a beaker for 1 h
destroys 100% of the chymotrypsin inhibitor activity and 80 to 100% of the trypsin inhibitor
activity.
Phytate: Phytate, or inositol hexaphosphate (IP6), is a naturally occurring compound found

in whole grains and legumes. It is the major storage form of phosphorous, comprising 1–5 %
by weight in cereals, legumes, oil seeds, and nuts. It represents 50–85 % of the total
phosphorous in plants, and grains. Phytic acid chelates cations, forming insoluble complexes
with minerals in the upper gastrointestinal tract. These complexes cannot be digested or
absorbed by humans because of the absence of intestinal phytase. However, during some
food-processing and storage practices, IP6 is dephosphorylated to lower myo-inositol
phosphate forms, some of which no longer inhibit mineral absorption.
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While moist heat at high temperature destroys most protease inhibitor activity, boiling beans
only reduced phytate content by an average of about 20%. Soaking grains and discarding the
water, fermentation and germination reduce phytates significantly.
Oxalate: Oxalic acid and its salts occur as end products of metabolism in several plant
tissues. Oxalic acid forms water-soluble salts with Na+, K+, NH4+ ions. It also binds with
Ca2+, Fe2+, and Mg2+, rendering these minerals unavailable for absorption. The primary
concern from a nutrient standpoint is oxalate’s impact on calcium absorption. Also, a high-
fiber and high-oxalate diet worsens calcium balance compared to a high-fiber or high-oxalate
diet alone.
It is well known that calcium absorption of high-oxalate vegetables is extremely poor. The
absorption index (calcium absorption of test source divided by the milk calcium absorption
value) of the high-oxalate vegetables Chinese spinach, rhubarb, and sweet potatoes was
0.257, 0.235, and 0.423, respectively, whereas from the low-oxalate vegetables Chinese
mustard greens and Chinese cabbage flower leaves, it was 1.080 and 1.097, respectively [54].
Lectins
Lectins: Haemagglutinins or Lectins are carbohydrate-binding proteins present throughout

nature that act as agglutinins. Approximately 30% of our food contains lectins, some of
which may be resistant enough to digestion to enter the circulation. Because of their binding
properties, lectins can cause nutrient deficiencies, disrupt digestion, and cause severe
intestinal damage when consumed in excess by an individual with dysfunctional enzymes.
These are proteins in nature and they occur widely in leguminous seeds. Haemagglutinins
reduce the food intake resulting in poor growth. The term “lectin” is broadly used to denote
“all plant proteins possessing at least one non-catalytic domain, which binds reversibly to a
specific mono- or oligosaccharide.
Many types of beans contain toxins called lectins, and kidney beans have the highest
concentrations – especially red kidney beans. As few as 4 or 5 raw beans can cause severe
stomach ache, vomiting and diarrhoea. Lectins are destroyed when the dried beans are soaked
for at least 12 hours and then boiled vigorously for at least 10 minutes in water. Tinned
kidney beans have already had this process applied and so can be used without further
treatment.
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Lathyrogens: Any of a group of nucleophilic compounds such as Oxalyl di amino

propionic acid ODAP, /3-N-Oxalylamino-L-alanine (L-BOAA) are a nonprotein derivatives
of amino acid present in the seed of Lathyrus sativus L. They act as metabolic antagonists of
glutamic acid, a neurotransmitter in the brain. They cause skeletal deformities and thinning of
collagen fibres resulting in damage to the bone and the other collagen fibres causing severe
muscle weakness and brittle bones.
Lathyrism is a disease caused by overconsumption of the khesari dhal. It has been reported
that excessive consumption (>300–400 g) of grass-pea or khesari continuously for three to
four months as a monotonous diet can lead to lathyrism. However, if consumed in smaller
quantities as a part of a normal mixed diet, its nutritional values can be optimally utilized.
Consumption of raw khesari dal or eating it with grain having high concentrations of sulphur
based amino acids reduces the risk of lathyrism. Food processing can reduce the toxins.
Amino acids which are toxic in nature are readily soluble in water and can be leached
entirely. Lactic acid and fungal fermentation are useful to reduce ODAP content. Moist heat
(boiling, steaming) denatures a protease inhibitor which adds to the toxic effect of a raw pea.
Role of WHO in safeguarding food toxin contamination
WHO, in collaboration with FAO, is responsible for assessing the risks to humans of natural
toxins – through contamination in food – and for recommending adequate protections.
Risk assessments of natural toxins in food done by the Joint FAO/WHO Expert Committee
on Food Additives (JECFA) are used by governments and by the Codex Alimentarius
Commission (the intergovernmental standards-setting body for food) to establish maximum
levels in food or provide other risk management advice to control or prevent contamination.
Codex standards are the international reference for national food supplies and for trade in
food, so that people everywhere can be confident that the food they buy meets the agreed
standards for safety and quality, no matter where it was produced.
JECFA sets the tolerable intake level for natural toxins: JECFA or ad hoc FAO/WHO
scientific expert groups consist of independent, international experts who conduct scientific
reviews of all available studies and other relevant data on specific natural toxins. The
outcome of such health risk assessments can either be a maximum tolerable intake (exposure)
level, or other guidance to indicate the level of health concern (such as the Margin of
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Exposure), including advice on risk management measures to prevent and control

contamination, and on the analytical methods and monitoring and control activities.
Exposure to natural toxins needs to be kept as low as possible to protect people. Natural
toxins not only pose a risk to both human and animal health, but also impact food security
and nutrition by reducing people’s access to healthy food. WHO encourages national
authorities to monitor and ensure that levels of the most relevant natural toxins in their food
supply are as low as possible and comply with both national and international maximum
levels, conditions and legislation.
12.6. FOOD LAWS AND STANDARDS
Codex Alimentarius
The Codex Alimentarius is a collection of internationally adopted food standards and related
texts presented in a uniform manner. These food standards and related texts aim at protecting
consumers’ health and ensuring fair practices in the food trade. The publication of the Codex
Alimentarius is intended to guide and promote the elaboration and establishment of
definitions and requirements for foods to assist in their harmonization and in doing so to
facilitate international trade. National official standards are set to safeguard the consumers’
health and ensure fair food trade practices. The 1963, the FAO and WHO established a
commission for setting up international food standards.
Codex Alimentarius are international standards set by FAO and WHO for the entire principal
foods, whether processed, semi-processed or raw. It includes standards regarding food
hygiene, food additives, pesticide residues, contaminants, labelling and presentation and
methods of analysis and sampling. A codex standard may be accepted by a country in its
entirety or with more stringent requirements for trade and distribution of food within its
territory.
Scope of the Codex Alimentarius
The Codex Alimentarius includes standards for all the principal foods, whether processed,
semi-processed or raw, for distribution to the consumer. Materials for further processing into
foods should be included to the extent necessary to achieve the purposes of the Codex
Alimentarius as defined. The Codex Alimentarius includes provisions in respect of food
hygiene, food additives, residues of pesticides and veterinary drugs, contaminants, labelling
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and presentation, methods of analysis and sampling, and import and export inspection and
certification.
Nature of Codex Standards
Codex standards and related texts are not a substitute for, or alternative to national legislation.
Every country’s law and administrative procedures contain provisions with which it is
essential to comply.
Codex standards and related texts contain requirements for food aimed at ensuring for the
consumer a safe, wholesome food product free from adulteration, correctly labelled and
presented. A Codex standard for any food or foods should be drawn up in accordance with
the Format for Codex Commodity Standards and contain, as appropriate, the sections listed
therein.
Codex standards ensure that food is safe and can be traded. The 188 Codex members have
negotiated science-based recommendations in all areas related to food safety and quality.
Codex food safety texts are a reference in WTO trade disputes. Student can visit official site
of Codex Alimentarius. https://www.fao.org/fao-who-codexalimentarius
Functions of Codex Alimentarius

International Food Standards increase trust of consumers, importers - Consumers can
trust the safety and quality of the food products they buy and importers can trust that the food
they ordered will be in accordance with their specifications.
Protecting Consumer Health - Public concerns about food safety issues often place Codex
at the centre of global debates. Veterinary drugs, pesticides, food additives and contaminants
are some of the issues discussed in Codex meetings. Codex standards are based on sound
science provided by independent international risk assessment bodies or ad-hoc consultations
organized by FAO and WHO.
Help countries to form their own food laws- While being recommendations for voluntary
application by members, Codex standards serve in many cases as a basis for national
legislation.
Removing Barriers to Trade: The reference made to Codex food safety standards in the
World Trade Organization's Agreement on Sanitary and Phytosanitary measures (SPS
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Agreement) means that Codex has far reaching implications for resolving trade disputes.
WTO members that wish to apply stricter food safety measures than those set by Codex may
be required to justify these measures scientifically.
Other important food regulations used by other countries
USA: There is a long-established system of food safety control and regulation The main
agencies involved at the federal level include the Food and Drug Administration (FDA) and
the Food Safety Inspection Service (FSIS) of the United States Department of Agriculture
(USDA).
European Union: The European food safety authority (EFSA) is the agency for EU’s food
safety standards. Health protection is the aim of all EU laws and standards in the agriculture,
animal husbandry and food production sectors.
Japan: The main law that governs food quality and integrity in Japan is the Food Sanitation
Act ("FSA") and the law that comprehensively governs food labelling regulation is the Food
Labelling Act. Apart from this for functional foods Japan also has Food for Specified Health
Uses (FOSHU). It refers to foods containing ingredient with functions for health and
officially approved to claim its physiological effects on the human body. FOSHU is intended
to be consumed for the maintenance / promotion of health or special health uses by people
who wish to control health conditions, including blood pressure or blood cholesterol.
Indian food regulatory regime
Indian Standards are based on the international Codex Alimentarius with suitable
modifications. They include
(a) Compulsory standards
(b) Voluntary standards
Compulsory Standards - Food Safety and Standards Act. 2006

The above acts of the food standards are being implemented through different agencies a new
act has been approved by the Government of India in 2006. This will be helpful as it is
implemented through a single agency. The FSSA 2006 is a statutory body for laying down
science-based standards for articles of food and regulating manufacture, distribution, sale and
import of foods so as to ensure safe and wholesome food for human consumption.
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FSSAI 2006 replaces the following acts:
The Prevention of Food Adulteration Act, 1954
The Fruit Products Order, 1955.
The Meat Food Products Order, 1973,
The Edible Oils Packaging (Regulation) Order, 1998.
The Vegetable Oil Products (Control) Order, 1947.
The Milk and Milk Products Order, 1992.
The Solvent Extracted Oil, De oiled Meal, and Edible Flour (Control) Order, 1967
Any other order issued under the Essential Commodities Act, 1955 relating to food
New food laws are evolved since 2006. The new act is called Food safety & Standards act.
FSSAI institute will be an independent govt. organization regulating all food laws in the
future. From September 2010 the change-over took place from PFA 1954 to FSSAI 2006.
Salient features of FSSA (2006)

 The act is user friendly
 Encourages all stake holders to suggest views.
 It is not a policing agency
 It will advise assist & educate food producers.
 Clear guide lines are given for implementation.
 The act wants stake holders to be honest & sincere in the implementation.
 The act treats the food processors with dignity
The FSSA (2006) act is implemented by Food Safety and Standards Authority of India
(FSSAI), which is an autonomous body established under the Ministry of Health & Family
Welfare, Government of India. The FSSAI has been established under the Food Safety and
Standards Act, 2006 which is a consolidating statute related to food safety and regulation in
India. FSSAI is responsible for protecting and promoting public health through
the regulation and supervision of food safety. The FSSAI has its headquarters at New Delhi.
The authority also has 6 regional offices located
in Delhi, Guwahati, Mumbai, Kolkata, Cochin and Chennai. Licensing is an important aspect
of FSSAI.
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Types of Licenses: FSSAI issues three types of licenses based on nature of food business
and turnover:
1. Registration: For Turnover less than ₹12 Lakh
2. State License: For Turnover between ₹12 Lakh to ₹20 Crore
3. Central License: For Turnover above ₹20 Crore
Numbering system: A uniform numbering system for issuance of licenses/registration will
be as follows:
1. Every license/registration number will have 14 digits.
2. The first digit will be signifying whether it is a license or it is registration -1 for
license and 2 for registration.
3. Next 2 digit will indicate State/UT/Centre.
Central licensing autjority will be indicated by 00 and the numbering for States will be as
follows:
01. Andhra Pradesh 10.Jammu & 19. Nagaland 28. West Bengal
Kashmir
02. Arunachal Pradesh 11. Jharkhand 20. Orissa 29. A & N Islands
03. Assam 12. Karnataka 21. Punjab 30. Chandigarh
04. Bihar 13. Kerala 22. Rajasthan 31.Dadra & Nagar
Haveli
05. Chhattigarh 14. Madhya Pradesh 23. Sikkim 32. Daman & Diu
06. Goa 15. Maharashtra 24. Tamil Nadu 33. Delhi
07. Gujarat 16. Manipur 25.Tripura 34. Lakshadweep
08. Haryana 17. Meghalaya 26. Uttarakhand 35. Puducherry
09. Himachal Pradesh 18. Mizoram 27.Uttar Pradesh
4. Next 2 digit will signify the year of start of the business. For those who are
already under a license, will apply for conversion to new licence as per provision
of the regulations. So 2011 will be indicated as 11.
5. Next 3 digit will signify the Designated/Registrar Officers under whose
jurisdiction a license/registration comes. So each State will assign digits from 00
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to 999 to Designated Officers and 001 to 999 to Registrar Officers. In case of
Central licensing the first digit will indicate the State which comes under a
particular designated officer. Further numbers can be alloted to Regional Offices
wherever they are opened.
6. The next 6 digit will signify the serial number of the buisness under a particular
designated officer. So each designated officer will have a capacity of ten lakh and
thus, will be able to accommodate large number of applications catering to the
needs of the growing sector.
Thus the allotment of digits will be as follows:
□ □□ □□ □□□ □□□□□□
License/Registration State/UT Year Designated/Registration Serial number of
Officer license/registration
To know more about FSSAI student can visit the official their website-
https://www.fssai.gov.in
Voluntary Standards
1. Bureau of Indian Standards (BIS): It is a voluntary standard i.e it is not compulsory
to comply with BIS standards by all food processing units unlike FSSA. The BIS
certification is more difficult to obtain as the standards are more stringent.
BIS is the National Standard Body of India established under the BIS Act 2016 for the
harmonious development of the activities of standardization, marking and quality
certification of goods. BIS has been providing benefits to the national economy in a number
of ways –
 providing safe reliable quality goods;
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 minimizing health hazards to consumers;
 promoting exports and imports substitute;
Manufacturers who comply with the standards laid down by BIS can obtain an Indian
Standards Institute (ISI) mark.
However, certain items like additives, food colours, vanaspati, milk powder, condensed milk
and packaging containers need compulsory certification by BIS.
The BIS Standard Mark (ISI Mark) is a mark of quality. Consumers as well as the
organized purchasers prefer ISI marked products. Some unscrupulous manufacturers try to
deceive the consumers by producing and marketing products with ISI mark and Hallmark
without obtaining license from BIS. In order to protect interests of consumers, BIS carries out
search and seizure, as and when information on such malpractices is received. Prosecution in
the Court of Law is launched against the offending firms after successful search and seizures.
Location: BIS has its Headquarters at New Delhi and its 05 Regional Offices (ROs) are at
Kolkata (Eastern), Chennai (Southern), Mumbai (Western), Chandigarh (Northern) and Delhi
(Central). Under the Regional Offices are the Branch Offices (BOs) located at Ahmedabad,
Bangalore, Bhubaneswar, BhopaSl, Coimbatore, Dehradun, Faridabad, Ghaziabad, Guwahati,
Hyderabad, Jaipur, Kochi, Lucknow, Nagpur, Parwanoo, Patna, Pune, Rajkot, Raipur,
Durgapur, Jamshedpur and Vishakhapatnam
To know more about BIS student can visit their official website - https://www.bis.gov.in
Agriculture Produce (Grading and Marketing) Act 1937 (Agmark): Agmark provides
standards for grading and marketing agricultural commodities. The consumer is assured of
the quality as per standards laid down. The standards / grades are based on physical and
chemical characteristics, intrinsic and acquired during processing or otherwise. Agricultural
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and allied commodities are graded 1, 2, 3 and 4 or special, good, fair and ordinary.
Manufacturers who comply with the standards laid down by Directorate of Marketing and
Inspection, put an AGMARK label on their product. Complying with these standards is not
compulsory.
To know more about AGMARK you may visit their official website -
https://agmarknet.gov.in
CHECK YOUR PROGRESS
Fill in the blanks
1. ____________ food production is at the level of farmers.

2. __________ is a recognized leader in the development of global food safety initiatives
3. _____________ are a common adulterant for pepper while water is used to commonly
adulterate milk.
4. Three common hazards are ___________, ____________ and ______________
hazards.
5. Mycotoxins are naturally occurring toxic compounds produced by certain types of
____________.
6. Protease inhibitors common in pulses include _____________ inhibitors.
7. Lathyrism is a disease caused by overconsumption of the __________________.
8. __________________ and ___________________ are two voluntary standards that
exist in India.
1. Define food quality and food safety.

2. Explain the term food adulteration.
3. What are the various harmful effects of adulteration?
4. What are common adulterants?
5. Write about the biological hazard.
6. What are natural toxins?
7. What are the functions of Codex Alimentarius?
8. How is a license issued by FSSAI?
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12.7. SUMMARY
Food safety and quality is essential from primary producer to the end consumer, often
described as from farm or pond to the plate approach. The food can get contaminated by
biological, physical and chemical hazards. The contamination may be intentional or
unintentional. Sometimes for improving the attribute of food foods are adulterated which can
cause harm to the health of consumer and economic losses to the manufacturer if the foods
are recalled. To ensure food safety there are food laws and regulations laid down
internationally by FAO/WHO outlined in the Codex Alimentarius or nationally by the
Government of India outlined in FSSAI. These are mandatory and are intended for consumer
protection. There are other voluntary food standards such as BIS and AGMARK for quality
assurance.
12.8. GLOSSARY
Word Meaning
Putrid decayed and having an unpleasant smell associated with rotting
meat
Exhausted spices Whole spices that have been used once e.g., to extract some of its
essential oil
Triorthocresyl Triorthocresyl phosphate (TOCP) is an organophosphorus
phosphate substance that has been responsible for several incidents of mass
poisoning.
Dulcin A highly toxic artificial sweetener
Brominated The emulsifier in the brominated vegetable oil helps the citrus
vegetable oil flavour blend properly in the soft drink. Brominated vegetable oil-
containing beverages have a hazy appearance.
Collagen Collagen is the main structural protein in the extracellular matrix
found in the body's various connective tissues. As the main
component of connective tissue, it is the most abundant protein in
mammals, making up from 25% to 35% of the whole-body protein
content.
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1. FSSAI, 2010, The training manual for food safety regulators, Vol I- Introduction to
food and food processing, Foods safety and standards authority of India, Ministry of
health & family welfare, FDA Bhavan, New Delhi.
2. https://www.fssai.gov.in
3. https://agmarknet.gov.in
4. https://www.fao.org/fao-who-codexalimentarius
Fill in the blanks
1. Primary food production is at the level of farmers.

2. FAO is a recognized leader in the development of global food safety initiatives
3. Papaya seeds are a common adulterant for pepper while water is used to commonly
adulterate milk.
4. Three common hazards are physical, chemical and biological hazards.
5. Mycotoxins are naturally occurring toxic compounds produced by certain types of
moulds.
6. Protease inhibitors common in pulses include trypsin inhibitors.
7. Lathyrism is a disease caused by overconsumption of the Khesari dhal.
8. Bureau of Indian Standards and AGMARK are two voluntary standards that exist in
India.
1. Define food quality and food safety.

According to the Food and Agriculture Organization of the United Nations (FAO), food
quality is “a complex characteristic of food that determines its value or acceptability to
consumers”. A food’s nutritional value contributes to its perceived quality, as do its
organoleptic and functional properties. Another element of quality is a food’s safety. Food
safety: According to FAO a safe food is one that is free of any substances that might
compromise a person’s health. WHO also has a similar definition, as per them-food Safety
can be defined as the assurance that food will not cause harm to the consumer when it is
prepared and or eaten according to its intended use.
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2. Explain the term food adulteration.

Food adulteration includes not only intentional addition or substitution or abstraction of
substances which adversely affect the nature, substances and quality of foods, but also their
incidental contamination during the period of growth, harvesting, storage, processing,
transport and distribution. A food adulterant may be defined as any material which is added
to food or any substance which adversely affects the nature, substance and quality of the
food.
3. What are the various harmful effects of adulteration?

There are many adulterants which might prove to be a hazard to our health especially if
consumed over a long period of time. E.g., chemicals like urea, sodium carbonate, sodium
hydroxide, formaldehyde and hydrogen peroxide added to increased shelf life of milk can be
harmful when ingested. Flavouring, colourings, preservatives, antioxidants etc. are all
chemicals which are safe only if eaten in very small quantities. Non-permitted colours like
auramine, Rhodamine B, Sudan red, Malachite green, orange II, lead to retardation of growth
and affects the proper functioning of vital organs like liver, kidneys, heart spleen, lungs,
bones and the immune systems. The commonly used metanil-yellow could be injurious to the
stomach, ileum, rectum, liver, kidney, ovary and testis. All the non- permitted colours can
also bring about changes in genes, most having been identified as potential cancer- causing
agents. Toxicity of permitted colours is also well demonstrated as allergic response to these
colours e.g., Tartrazine.
Economic impact of adulteration is also significant and involve value of food rendered unfit
for consumption and cost of treating people who have fallen sick, been disabled or the heavy
cost of lives lost. When exported adulterated foods have to be often recalled, cases are filed
resulting in loss of credibility in the international market.
4. What are common adulterants?

Foods commonly adulterated include - food grains and their products, edible oils and fats,
spices, both whole and ground, ghee and milk powder, coffee and tea, sugar and honey,
beverages and items like confectionary, jams, sauces, ice creams and prepared foods items.
Foods gets adulterated at different stages of manufacturing and marketing.
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5. Write about the biological hazard.

Biological hazards include bacterial, fungal, viral and parasitic (protozoa and worms)
organisms and/or their toxins. There are many microorganisms which are pathogenic in
humans but relatively few are associated with foods and those are, are termed food-borne
pathogens. There are two types of food-borne disease from microbial pathogens: infections
and intoxications. Infections result from ingestion of live pathogenic organisms which
multiply within the body and produce disease. Intoxications occur when toxins produced by
pathogens are consumed. Intoxications can occur even if no viable microorganisms are
ingested. This often occurs when foods are stored under conditions which allow the
pathogens to grow and produce toxin. Subsequent processing of the food may destroy the
microorganisms but not the toxin. The microorganisms may give a mild to severe level of
adverse reaction in the host.
6. What are natural toxins?

According to WHO, natural toxins are toxic compounds that are naturally produced by living
organisms. These toxins are not harmful to the organisms themselves but they may be toxic to
other creatures, including humans, when eaten. These chemical compounds have diverse
structures and differ in biological function and toxicity. Some toxins are produced by plants
as a natural defence mechanism against predators, insects or microorganisms, or as
consequence of infestation with microorganisms, such as mould, in response to climate stress
(such as drought or extreme humidity). Other sources of natural toxins are microscopic algae
and plankton in oceans or sometimes in lakes that produce chemical compounds that are toxic
to humans but not to fish or shellfish that eat these toxin-producing organisms.
7. What are the functions of Codex Alimentarius?

Functions of Codex Alimentarius are:
 International Food Standards increase trust of consumers, importers.
 Public concerns about food safety issues often place Codex at the centre of global
debates. Codex standards are based on sound science provided by independent
international risk assessment bodies or ad-hoc consultations organized by FAO
and WHO.
 Help countries to form their own food laws
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 Removing Barriers to Trade: The reference made to Codex food safety standards
in the World Trade Organization's Agreement on Sanitary and Phytosanitary
measures (SPS Agreement) means that Codex has far reaching implications for
resolving trade disputes.
8. How is a license issued by FSSAI?

Licensing is an important aspect of FSSAI. FSSAI issues three types of licenses based on
nature of food business and turnover:
 Registration: For Turnover less than ₹12 Lakh
 State License: For Turnover between ₹12 Lakh to ₹20 Crore
 Central License: For Turnover above ₹20 Crore
A uniform numbering system for issuance of licenses /registration is followed.
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BLOCK-IV: COMMUNITY BASED HEALTH AND NUTRTION APPROACHES/

STRATEGIES
Health-based interventions play an important role in the overall health, longevity, and
productivity of a community, as they can improve quality of life, reduce human suffering,
help children thrive, and save money. The people and programs involved in public health
work to create the healthiest nation possible. Food-based nutrition interventions include the
development of community gardens and farms in urban and rural areas; hydroponic gardens
and other related initiatives in urban and periurban agriculture; as well as the promotion of
traditional crops with nutritional value and the development of small agro-industries. Food-
based nutrition interventions can be implemented to improve the food supply in the street and
itinerant markets, town squares, rural markets, and street food sales. In all food-based
interventions, food safety and quality control must be taken into consideration throughout the
food chain.
The nutrition intervention is the third step in the Nutrition Care Process and it
involves both planning and implementing an intervention to improve the patient’s nutritional
health outcome, specifically targeted at the nutrition diagnosis. Different types of intervention
include food fortification, supplementation, and behavioral and regulatory interventions
which have an impact on nutrition outcomes. The importance of good nutrition throughout all
life stages is well established and a poor nutritional intake has implications for the
development of many health issues including non-communicable diseases such as cancers,
cardiovascular diseases, and stroke.
LEARNING OUTCOME:
 Understand the importance of health-based intervention, importance of Immunization,

hygiene and sanitation and prevention of malnutrition.
 Understand the different ways of food-based intervention and its uses and the method
of food fortification and its importance.
 Know the importance and goals of nutrition intervention education and health and
nutrition-related behavioral change in the community.
 Describe the need, scope, overall process, and criteria for designing of nutrition
education.
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UNIT-13: HEALTH-BASED INTERVENTIONS
13.0: OBJECTIVES
13.1: INTRODUCTION
13.2: TYPES OF PUBLIC HEALTH BASED INTERVENTION
13.3: IMMUNIZATION
13.4: NATIONAL IMMUNIZATION SCHEDULE
13.5: SAFE DRINKING WATER/ SANITATION
13.6: ROLE OF KITCHENS GARDEN IN COMBATING MALNUTRITION
13.7: BENEFITS OF KITCHENS GARDEN
13.8: IMPORTANCE OF NUTRITION GARDEN
13.9: SUMMARY
13.12: GLOSSARY
13.13: REFERENCES
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13.0: OBJECTIVES
After studying this unit, you can;

 Understand the importance of health-based intervention.
 Discuss the importance of Immunization.
 Know the role of safe drinking water, and the importance of hygiene and sanitation.
 Discuss the role of kitchens garden in the prevention of malnutrition.
13.1: INTRODUCTION
Health-based interventions in public have saved millions of lives since 1854 when Dr. John
Snow first identified public water well as the source of a major cholera outbreak in London.
In the decades since, public health interventions have been instrumental in improving the
health and well-being of people in large and small communities.
Health-based intervention is an organized effort to promote those specific behaviors and

habits that can improve physical, mental, and emotional health. These interventions can also
reframe the perspective of unhealthy habits to change the way people think about those
behaviors.
Health-based interventions play an important role in the overall health, longevity, and
productivity of a community, as they can improve quality of life, reduce human suffering,
help children thrive, and save money. The people and programs involved in public health
work to create the healthiest nation possible.
In this unit, public health-based interventions include the following;
 Vaccination
 Safe Drinking Water/ Sanitation
 Role of Kitchens Garden in Combating Malnutrition
This will helps to save lives and reduce disability in the community for better lively wood.
Public health intervention programs can be cost-effective solutions to some of the most
pressing community health issues in the nation today.
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13.2: TYPES OF PUBLIC HEALTH BASED INTERVENTION
Today's public health requires a multidisciplinary team of public health workers that might
include epidemiologists, biostatisticians, public health nurses, medical assistants, midwives,
or medical microbiologists. Together, they can implement a variety of preventive and/or
responsive interventions, including the six outlined below.
1. Epidemiology and Surveillance:

Epidemiology focuses on the causes and distribution of infectious diseases and other health
issues and works to stop them from spreading. Epidemiologists, public health physicians,
nutritionists, nurses, and public policymakers participate in epidemiology and surveillance
work. Research by epidemiologists and other epidemiology professionals can impact
maternal and child health, environmental health, responses to bioterrorism, substance abuse,
and other public health issues.
2. Outreach:
Outreach programs identify populations of interest or populations at risk and provide
information about the nature of a particular health concern, possible solutions, and ways
residents can obtain medical services. Outreach specialists help promote affordable
healthcare options and provide health education, advocacy, and community awareness around
public health issues such as obesity, stress, maternal and childhood health, and sexually
transmitted infections.
3. Screening:
Population-based screening is an essential component of public health because it helps
identify individuals with asymptomatic diseases or unrecognized health risk factors.
Screening has two main goals: Identifying diseases in their early stages and identifying risk
states, such as high blood pressure, so that patients may begin treatment early. Public health
screening may include newborn screening for genetic disorders and mammography to detect
breast cancer before it is palpable.
4. Health and Nutrition Teaching:

Professionals responsible for public health teaching interventions communicate ideas, facts,
and skills that can change the level of knowledge, attitudes, behaviors, beliefs, values, and
practices of communities, systems, families, and individuals. They work in a variety of
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settings, including schools, hospitals, and community health centers. Public health educators
work to ensure that community members understand health risks and concerns relevant to
their age group and location. Nutritionist plays an important role in educating the community
people to follow the proper diet, food preferences, and adequate eating to maintain nutritional
status.
5. Social Marketing:
Social marketing seeks to bring about behavioral changes that improve health. Social
marketing may be effective for the promotion of breastfeeding practices in community and
workplace settings, for example, and can help educate policymakers about the benefits of
breastfeeding.
6. Policy Development:
Public health professionals play an important role in the policy-making process by
conducting analyses of similar policies and communicating their findings, developing
partnerships between decision-makers and healthcare providers, and promoting and
implementing evidence-based public health interventions.
13.3: IMMUNIZATION
Immunization is important in the specific control and prevention of communicable diseases.

Immunization is the process by which a person becomes protected against a disease through
an enhancement of their immune response. It is a simple and effective way of protecting
children from serious diseases. It not only helps protect individuals, but it also protects the
broader community by minimizing the spread of disease. The term immunization is different
from vaccination. A vaccine is a form of immunization where the body learns to recognize a
particular foreign object. Vaccines work by triggering the immune system to fight against
certain diseases. If a vaccinated person comes in contact with these diseases, their immune
system can respond more effectively, preventing the disease from developing or greatly
reducing its severity.
Immunization is the process whereby a person is made immune or resistant to an infectious
disease, typically by the administration of a vaccine. Vaccines stimulate the body's immune
system to protect the person against subsequent infection or disease. Immunization is a
proven tool for controlling and eliminating life-threatening infectious diseases and is
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estimated to avert between 2 and 3 million deaths each year. It is one of the most cost-
effective health investments, with proven strategies that make it accessible to even the most
hard-to-reach and vulnerable populations. It has clearly defined target groups; it can be
delivered effectively through outreach activities, and vaccination does not require any major
lifestyle change.
Immunization protects against many serious childhood diseases including whooping cough,
tetanus, tuberculosis, malaria, chicken pox, measles, German measles, polio, diphtheria,
mumps, rotavirus, meningococcal C, pneumococcal, and hepatitis. These diseases can cause
hospitalization, and serious ongoing health conditions including cancer, brain damage, and
deafness, and are sometimes fatal. High immunization rates in the community have led to
many of these diseases becoming rare.
However, they still exist and risks of side effects or complications from these diseases are far
greater than the very small risks of side effects from vaccination. Besides these effects, some
children may be allergic to vaccines. There are two forms of allergic reaction –immediate
reaction and delayed – serum sickness. The symptoms of immediate reactions are cold sweat,
rapid/weak pulse, difficulty breathing, a skin rash may appear and unconsciousness
sometimes death may occur. Emergency treatment should be provided as soon as the above-
mentioned symptoms are observed. As a prevention step, it is advisable to go for a sensitivity
test or skin test. The precautions to be undertaken while administering vaccines or
immunizing the children.
 Immunization should normally be given to good individuals only and Immunization

should be postponed if the children are ill or have fever, cough, running nose, or skin
conditions.
 It is very essential to children with malnutrition should have immunizations along with
advising the parents of the child to give extra protein foods and enough energy foods to
help the body develop immunity.
 The giving of oral polio drops should be postponed if children have vomiting or diarrhea
 Children should be restrained while giving immunization.
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13.4: NATIONAL IMMUNIZATION SCHEDULE
Immunization is one of the most important and cost-effective strategies for the prevention of
childhood sicknesses and disabilities and is thus a basic need for all children. The following
schedule has been recommended by the Ministry of Health, Govt. of India and is one of the
most widely followed by child health care providers.
Vaccine When to give Maximum Dose Route Site

age
For Pregnant Women
Tetanus & adult early -- 0.5ml intra muscular Upper arm

Diphtheria (Td -1) pregnancy
Tetanus & adult 4 weeks after -- 0.5ml intra muscular Upper arm
Diphtheria (Td -2) 1st dose of
Td*
Tetanus & adult If received 2 -- 0.5ml intra muscular Upper arm
Diphtheria (Td Td doses in
booster) pregnancy
within the last
3yrs
For Infants
BCG (Bacillus At birth or as From birth 0.1ml Intra-dermal Left Upper
Calmette Guerin) early as till one year (0.05ml Arm
possible till 1 until
year of age 1month
age)
Hepatitis B - Birth At birth or as At birth 0.5 ml Intra-muscular Antero-
dose early as within 24 lateral side
possible within hours of mid-
24 hours thigh
Oral Polio Vaccine At birth or as Within the 2 drops Oral Oral
(OPV) -0 early as first 15 days
possible within
the first 15
days
Oral Polio Vaccine 6 weeks, 10 Till 5 years 2 drops Oral Oral
(OPV) -1,2,3, weeks & 14 of age
weeks
Inactivated Polio 6 weeks & 14 1 year of 0.1 ml Intra-dermal Right
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Vaccine (IPV) 1 & weeks age Upper arm

2
Pentavalent 6 weeks, 10 1 year of 0.5 ml Intra-muscular Antero-
vaccine weeks & 14 age lateral side
(Diphtheria, weeks of mid-
Pertussis, Tetanus, thigh
Hepatitis B, Hib)-
1, 2 & 3
Rotavirus Vaccine At 6 weeks, 10 1 year of 5 drops Oral Oral
(RVV) 1, 2 & 3 weeks & 14 age (lyophili
weeks zed
vaccine)
Pneumococcal At 6 weeks, 14 1 year of 0.5 ml Intra-muscular Antero-
Conjugate Vaccine weeks & 9 age lateral side
(PCV) 1, 2 & months of mid-
Booster thigh
Measles-Rubella 9 completed 5 years of 0.5 ml Sub-cutaneous Right
(MR) 1 months - to 12 age upper arm
months. Give
up to 5yrs if
not received at
9 - 12 months
of age
Vitamin A (1st At 9 completed 5 years of 1ml Oral Oral
dose) months age (1lakh
IU)
Japanese At 9 completed 15 years of 0.5 ml Subcutaneous Left upper
Encephalitis (1st months - 12 age (live vaccine) arm
Dose)*** months Intramuscular Antero-
(killed) lateral side
of mid-
thigh
For Children and adolescents
Diphtheria 16- 24 months 7 years of 0. 5 ml Intramuscular Antero-
Pertussis Tetanus age lateral side
(DPT) booster 1 of mid-
thigh
MR 2 16-24 months 5 years of 0.5 ml Sub-cutaneous Right
age Upper arm
OPV Booster 16-24 months 5 years of 2 drops Oral Oral
age
Japanese Encephali 16-24 months 15 years of 0.5 ml Sub-cutaneous Left Upper
tis***(if age Arm
applicable)
Vitamin A***(2nd 18 months 5 years of 2 ml (2 Oral Oral
to 9th dose) (2nd dose). age lacks IU)
Then, one dose
every 6 months
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up to the age
of 5 years.
Diphtheria 5- 6 years 7 years of 0.5 ml Intra-muscular Upper arm
Pertussis Tetanus age
Booster (DPT)
booster 2
Tetanus & adult 10 years &16 16 years of 0.5 ml Intra-muscular Upper arm
Diphtheria years age
* Give Td-2 or Booster doses before 36 weeks of pregnancy. However, give these even if
more than 36 weeks have passed. Give Td to women in labor if, she has not previously
received Td.
Pentavalent vaccine (containing Diphtheria+Pertussis+Tetanus+Hepatitis B+Hib)
*** JE vaccine at select endemic districts.
Rotavirus vaccine (RVV) as part of the Universal Immunization Programme
In India, every year 37 out of every 1000 children born are unable to celebrate their 5th
birthday, and one of the major reasons for this is diarrheal deaths. Out of all the causes of
diarrhea, rotavirus is a leading cause of diarrhea in children less than 5 years of age. It is
estimated that rotavirus cause 8,72,000 hospitalizations; 32,70,000 outpatient visits and an
estimated 78,000 deaths annually in India. The introduction of the Rotavirus vaccine will
enable it to directly address the problem of diarrheal deaths.
The rotavirus vaccine was introduced in 2016 in a phased manner, beginning with 4 states
initially and later expanding to 7 more states making it a total of 11 states by end of 2018,
where the Rotavirus vaccine was available in the country. The vaccine has been further
expanded to 17 more states. Rotavirus vaccine is now available in 28 States/UTs, namely,
Andhra Pradesh, Haryana, Himachal Pradesh, Jharkhand, Odisha, Assam, Tripura,
Rajasthan, Tamil Nadu, Madhya Pradesh, Uttar Pradesh, Manipur, Daman & Diu, Gujarat,
Bihar, Sikkim, Arunachal Pradesh, Chhattisgarh, Maharashtra, Dadra & Nagar Haveli, Goa,
Chandigarh, Nagaland, Delhi, Mizoram, Punjab, Uttarakhand, and Andaman and Nicobar
Islands. The vaccine is expected to be available in all 36 States/UTs by September 2019.
Pentavalent vaccines:
The pentavalent vaccine is a combination of DPT (diphtheria, Pertussis/whooping cough, and

tetanus), Hepatitis B, and Hib vaccines. DPT and Hepatitis B vaccines are already a part of
the immunization program. They are being replaced by the pentavalent vaccine in a phased
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manner in the country. Each pentavalent vaccine consists of a 0.5ml dose that will be given
intramuscularly in the mid-thigh region through syringes.
The revised immunization schedule, when pentavalent vaccines are introduced is as follows.
Vaccine Schedule
BCG, Hep B birth dose, OPV-O At Birth
Pentavalent (DPT + Hep B + Hib), OPV 6 weeks, 10 weeks, and 14 weeks
Measles and Vitamin A 9-12 months
DPT booster, OPV booster, Measles2* 16-24 months
DPT booster 5-6 years
Introduction of Pneumococcal Conjugate Vaccine (PCV) under the Universal

Immunisation Programme
The Health Ministry has approved the introduction of the Pneumococcal Conjugate Vaccine
(PCV) under the Universal Immunisation Programme. Himachal Pradesh will be among four
other states where Pneumonia Vaccines will be introduced along with Bihar, Uttar Pradesh,
Rajasthan, and Madhya Pradesh in a planned manner from 2017.
IAP (Indian Academy of Pediatrics) Recommendations:
Indian Academy of Pediatrics, the largest professional organization of pediatricians in our

country, fully endorses and supports the national schedule. It supplements the above schedule
further, with additional vaccines such as the Hepatitis B vaccine to be given in three doses (at
birth, one month, and six months of age.) and MMR (Measles, Mumps & Rubella vaccine) at
about 15 to 18 months of age. It must be remembered that even though rubella may appear to
be a mild illness, it has a serious potential to cause congenital defects in a baby, whose
mother is not protected against rubella and catches the infection during early pregnancy.
Age Vaccines
Birth BCG, OPV 0, Hepatitis B -1
6 weeks IPV-1, DTwP-1, Hepatitis B -2, Hib -1, Rotavirus 1, PCV 1
10 weeks DTwP-2, IPV 2, Hib -2, Rotavirus 2, PCV 2, Hep B 3
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14 weeks DTwP-3 , IPV-3 , Hib -3, Rotavirus 3, PCV 3, Hep B 4

6 months Influenza (IIV) 1
7 months Influenza (IIV) 2
6-9 months Typhoid Conjugate Vaccine
9 months MMR I
12 months Hep-A 1
15 months MMR 2, Varicella 1, PCV Booster
16-18 months DTwP B 1 / DTaP booster -1, IPV B 1, Hib booster 1
18 - 19 months Hep-A 2, Varicella 2
4 - 6 years DTwP B 2 / DTaP booster -2, IPV B 2, MMR 3
10 - 12 years Tdap / Td, HPV (Only for females, three doses at 0, 1-2, and
6 months
Abbreviations: BCG: Bacillus Calmette Guerin, OPV: Oral poliovirus vaccine,

DTwP: Diphtheria, tetanus, whole cell Pertussis, DT: Diphtheria and tetanus toxoids,
TT: Tetanus toxoid, Hep B: Hepatitis B vaccine, MMR: Measles, Mumps and Rubella
Vaccine, Hib: Hemophilus influenza Type ‘b’ Vaccine, IPV: Inactivated poliovirus vaccine,
Td: Tetanus, reduced dose diphtheria toxoid, HPV: Human Papilloma Virus Vaccine,
PCV: Pneumococcal Conjugate Vaccine, TdaP: Tetanus and Diphtheria Toxoids and a
Cellular Pertussis Vaccine.
WHO-INDIA RECOMMENDATION:
W H O recommended an Immunization Schedule.
Vaccine Age
Birth 6 weeks 10 weeks 14 weeks 9-12months
Recommendations for all children
BCG X
Polio X X X X
DTP X X X
Hepatitis B* X X X X
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Rotavirus X X X
Haemophilus influenzae type b X X X
Pneumococcal (Conjugate) X X X
Measles X
Rubella X
13.5: SAFE DRINKING WATER/ SANITATION
Safe drinking water, sanitation, and hygiene (WASH) are fundamental to improving the
standards of living for people. The improved standards made possible by WASH include,
among others, better physical health, protection of the environment, better educational
outcomes, convenience time savings, assurance of lives lived with dignity and equal
treatment for both men and women. Poor and vulnerable populations have lower access to
improved WASH services and have poorer associated behaviors. Improved WASH is
therefore central to reducing poverty, promoting equality, and supporting socioeconomic
development.
Benefits of safe drinking water:
Water of satisfactory quality is the fundamental indicator of the health and well-being of a
society and hence, crucial for the development of a country. Contaminated water not only has
the potential to pose an immediate threat to humans but also can affect an individual
productive rate. According to the WHO report, an estimated 1.1 billion people in the world
drink unsafe water. Approximately 3.1% of the global annual death (1.7 million) and 3.7% of
the annual burden (disability) (54.2 million) are caused by the use of unsafe water and lack of
basic sanitation and hygiene.
Water provides several benefits and services for humans and the ecosystem. The benefit of
water is not documented sufficiently, resulting in low political priority for water issues and
suboptimal levels of investment in water infrastructures. The same document also indicates
that the benefit of water is mostly hidden in other technical documents. Safe water has a great
role in addressing developmental challenges, such as human health, food, and energy
security, urbanization and industrial growth, as well as climate change. Especially, there is a
strong nexus between water, food, and energy.
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Millions of people die due to water-related diseases like cholera, diarrhea, malaria, dengue
fever, and so on. Globally, water-borne diseases kill more than 25,000 people per day and
about 5000 children die per day due to water-related diseases (mainly diarrhea), most of
which can be easily prevented. Diarrhea and related diseases kill about 1.8 million children
every year, most of which are in developing countries. In many parts of the world, especially
developing countries, water-borne diseases represent the leading cause of death. Thus, access
to safe water means a reduction of water-related diseases. It is an opportunity for improved
health because it reduces the outbreak of health hazards.
“Water sustains life but safe, clean drinking water defines civilization.”
The benefit of water extends to other developmental activities/sectors such as health,

education, agriculture, food production, energy, industry, and other social and economic
activities
Basic principles of safe drinking water:
There are basic standards, norms, criteria, and indicators for safe drinking water. There are
also policies, strategies, and programs for safe drinking water. Norm refers to the standard of
development related to the large group of society. Criterion refers to the agreed norm or
standard used for the decision. The indicator refers to the measured value of individual water
quality parameters. Standard refers to the agreed target/threshold value established as an
agreed target, which is set by an authority. There are various water quality standards and
criteria in the world.
Water regulations are important for the provision of drinking water that is sufficient in
quantity, safe, accessible, acceptable, affordable, and reliable. Drinking water regulations
include controlling the water supply systems which are water source, water treatment,
distribution, use, wastewater, and gray water. Countries regulate drinking water differently
depending on the quality of their water source.
An adequate, clean, and safe drinking water supply has to be available for various users.
Moreover, water has to be accessible for all, including children, elders, and disabled ones.
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Water availability refers to both sufficient quantities and reliability of service provisions.
Adequacy refers to both the quality and quantity of water. Reliability refers to the continuity
of the service provider for the current and future generations, which is covered under the
principle of sustainability, system robustness, and resilience. Acceptability refers to the
aesthetic value of water – the acceptable appearance, taste, and odor of water. It is a highly
subjective parameter and largely depends critically on the perceptions of the local ecology,
culture, education, and experience hence, there are no set clear and objective global
acceptability standards. Accessibility to water refers to the accessibility to a reliable supply
of water continuously close to the point of demand: within everyone's reach: home, school,
work, and public places.
The role of a drinking water supplier is to provide adequate water for the community and
prevent/mitigate the risk of water contamination in different elements/points of the water
supply system such as source, treatment, and distribution. They also should assure the
delivery of safe and esthetically pleasing drinking water to the consumer's point. In general,
the prevention, mitigation, and elimination of water contamination are the responsibilities of
water providers and regulators. Water regulations are also important for the provision of
drinking water that is sufficient in quantity, safe, accessible, acceptable, affordable, and
reliable.
As water is a basic need for human life, access to clean, and safe drinking water is a basic
human right. As a criterion, an adequate, reliable, clean, acceptable, and safe drinking water
supply has to be available for various users. Moreover, everyone needs access to safe water in
adequate quantities for drinking, cooking, and personal hygiene and sanitation facilities that
do not compromise health or dignity. Some of the factors are related to infrastructures
(aging), clean water issues (quality, scarcity), natural factors (climate change, flood, and
drought), human factors (population growth, migration, demographic change, economic
development, willingness to pay for water supply services, overuse), water management and
delivery problems (pressure, leakages, lack of smart water meters, cost recovery, operation
costs, etc.). In developing countries, improving access to safe water requires the provision of
good quality education and the establishment of good governance. Priorities should be given
to the development of a democratic government and community empowerment.
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Guidelines for Safe drinking-water:
 Even if it looks clear, water can contain cholera germs.

 Boil or add drops of chlorine to the water before drinking.
 Keep drinking water in a clean, covered pot or bucket, or other containers with a
small opening and a cover. It should be used within 24 hours of collection.
 Pour the water from the container - do not dip a cup into the container.
 If dipping into the water container cannot be avoided, use a cup or other utensil with a
handle.
13.6: ROLE OF KITCHENS GARDEN IN COMBATING MALNUTRITION
Malnutrition is a rapidly growing problem across the country. Malnutrition not only slows
down child growth and development but also increases the risk and duration of aging sick and
also hindered social and mental development. The main cause of malnutrition is the lack of
nutrients in the diet. Most people depend on grains for food, and less consumption of
vegetables, and green vegetables; fruits and milk is the reasons for malnutrition. Diet
diversification is the best strategy to improve health and nutrition, especially for the poor.
Fruits and vegetables are the best way to make healthy beer, overcoming hunger and
malnutrition.
The magnitude of malnutrition and the ignorance about the relationship between food and
health among a majority of the population at all levels necessitates the need for nutrition
education. This approach in long term may promote self-reliance and self-support in the
communities. Nutrition intervention programs have been taken up and are being implemented
by the central, and state governments, and voluntary agencies to improve the nutritional
status and health of the vulnerable sections of the population. Homestead gardening can play
a significant role in improving food security for rural households as well as middle-class
urban households in developing countries like India.
Kitchen gardening is a revolutionary step to increase vegetable production as well as the

provision of cheap vegetables to consumers. Vegetables are a major source of vitamins,
minerals, and fiber. They are a very important part of our diet as they contain various
nutrients for many body functions. Vegetables also provide taste, palatability, better
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digestibility to us, and increase appetite. Vegetables are suitably grown in kitchen gardens as
they are mostly short-duration crops. A family can take vegetables from these kitchen
gardens around the year. The nutritional kitchen garden is generally located close to the
house and is used for growing vegetables, fruits, and other food crops for the family. It not
only saves our money and time but also can provide a healthy, useful, and environment-
friendly hobby for the whole family.
Picture -1 Method of Kitchen Gardens
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Kitchen gardens can help us in the recycling of household waste especially when a compost
pit is developed. One of the easiest ways of ensuring access to a healthy diet that contains
adequate macro- and micronutrients is to produce many kinds of foods in the home garden.
This is especially important in rural areas where people have low purchasing power and
distant markets. Kitchen gardening directly provides food and nutritional security by making
access to food that can be harvested instantly, prepared, and fed to family members, daily or
whenever required. Home gardens are also becoming an increasingly important source of
food and income for poor households in peri-urban and urban areas. Kitchen gardens can be
grown in the spaces available in the backyard of the house or roof or they can be established
with joint efforts on a commonplace or land. The term malnutrition implies both nutrition
including micronutrient deficiencies and over-nutrition.
After over 70 years of independence, India is still a country in developmental transition and
continues to battle with infectious diseases and conditions related to undernutrition. Apart
from having a good amount of production of vegetables at the national level, the per capita
availability in the diet is quite low in our country. The daily requirement of vegetables is
around 300 gms as per ICMR but the availability is very low. Many rural families used to
grow vegetables in their backyards for their household consumption. But still, they lack
adequate consumption of vitamins and minerals because of the unorganized cultivation of
vegetables.
Nutrition is considered critical for children and women. Nutrition is an input into
development especially economic development and its neglect would adversely affect health,
and cognition. Kitchen garden established in household ensures the daily supply of fresh
vegetables in the diets and have helped to improve the food and nutritional security of women
as well as their family members.
The five-year plans enunciated the outlined multi-sectoral program to multi-pronged
strategies for improving food security and to improve the nutritional status of the population.
This laid the goals to be achieved in a specified time frame and provided the needed funds to
implement the interventions. As a result of all interventions, famines and severe food
insecurity are no longer a threat but even today seasonal food insecurity is seen in different
pockets of the country. The set of interventions recommended addresses mainly the "Food"
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and nutrient intake needs of mothers and children because this is where most of the
quantitative evidence of efficiency and effectiveness lies.
13.7: BENEFITS OF KITCHENS GARDEN
 A kitchen garden is an integrated system that comprises the family house, a

recreational area, and a garden producing a variety of foods including vegetables,
fruits, and medicinal plants for home consumption or sale.
 The kitchen/home gardens have been found to play an important role in improving
food security for resource-poor rural households in developing countries.
 Vegetable production can be easily made accessible particularly to the poor through
kitchen gardens and this call for nutrition intervention and extensive nutrition
education.
 Kitchen gardening continues to be the best way of improving the diets and nutritional
status of the population.
 Kitchen gardening can thus be argued to improve access to food for vulnerable
groups.
 Kitchen gardens provide and supplement subsistence requirements and generate
secondary direct or indirect income.
 Besides the provision of fruits and vegetables, gardening provides an aesthetic and
therapeutic exercise that helps in relieving stress.
 Gardening promotes relief from acute stress, which further improves the well-being of
people.
 Nutrition is considered critical for children and women. Nutrition is an input into
development especially economic development and its neglect would adversely
impact health and cognitive development.
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Figure -1 Benefits of Kitchen Garden
13.8: IMPORTANCE OF NUTRITION GARDEN
Promoting local plants is a suitable strategy to increase vegetable consumption in a particular

area. Many local plants have anti-oxidative compounds, anti-mutagenicity, and anti-
inflammatory properties. Nutrition awareness programs emphasize the need to include locally
available fruits and vegetables like papaya, mango, guava, and leafy vegetables in their daily
diet. Hence every family or every citizen has a vital role in converting his surrounding vacant
land into a live kitchen garden, where location specific seasonal vegetables and fruits are
grown. The main purpose of a nutrition garden is to provide the family daily with fresh
vegetables rich in nutrients and energy.
A scientifically designed nutritional garden helps to meet the complete requirements of fruits
and vegetables for a family throughout the year. The fruits and vegetables are consumed by
purchasing them from the market but for each small and marginal family, it is not possible to
include them in daily life. A healthy vegetarian person should consume at least 125 grams of
leafy vegetables, 100 grams of root vegetables,75 grams of other vegetables, and 85 grams of
fruits, besides 475 grams of grains and 85 grams of pulses in their daily diet.
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To ensure a healthy diet, fruits and vegetables are to be grown systematically in a small piece
of land available in a home which is known as a nutrition garden. This is important in rural
areas where people have limited income and poor access to markets. Location specific
programs like the promotion of nutrition gardens will play a major role in solving the
problem of malnutrition. The concept of the nutritional garden aims at a continuous supply of
vegetables to meet the daily needs of the family from the available area utilizing household
wastes using organic matter including water. The development and maintenance of a nutrition
garden is a collective effort of family members led by a woman or housewife.
The establishment of kitchen gardens has a huge role in tackling the problem of malnutrition
and micronutrient deficiencies in rural areas. Enhanced consumption of fruits and vegetables
is the cheapest and easiest way to maintain good health. Backyard kitchen gardening
contributes to household food security by providing direct access to food that can be
harvested, prepared, and fed to family members, often daily. Even very poor or landless
people can also do gardening on small pieces of land, empty plots, or in containers.
Therefore, Kitchen gardening is a good means to improve household food security, it should
be courageous and adopted in the entire country. The kitchen garden provides an opportunity
to farm women and family members to earn money and engage themselves in work along
with proper utilization of place and water.
13.9: SUMMARY
 Health-based interventions play an important role in the overall health, longevity, and
productivity of a community, as they can improve quality of life, reduce human
suffering, help children thrive, and save money.
 Today's public health requires a multidisciplinary team of public health workers that
might include epidemiologists, biostatisticians, public health nurses, medical assistants,
midwives, or medical microbiologists.
 Epidemiology focuses on the causes and distribution of infectious diseases and other
health issues and works to stop them from spreading.
 Population-based screening is an essential component of public health because it helps
identify individuals with asymptomatic diseases or unrecognized health risk factors.
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 Nutritionist plays an important role in educating the community people to follow the
proper diet, food preferences, and adequate eating to maintain nutritional status.
 Immunization is important in the specific control and prevention of communicable
diseases. Immunization is the process by which a person becomes protected against a
disease through an enhancement of their immune response.
 Safe drinking water, sanitation, and hygiene (WASH) are fundamental to improving the
standards of living for people.
 Water provides several benefits and services for humans and the ecosystem.
 Malnutrition is a rapidly growing problem across the country. Malnutrition not only
slows down child growth and development but also increases the risk and duration of
aging sick and also hindered social and mental development.
 Kitchen gardening is a revolutionary step to increase vegetable production as well as the
provision of cheap vegetables to consumers. Vegetables are a major source of vitamins,
minerals, and fiber.
 The nutritional kitchen garden is generally located close to the house and is used for
growing vegetables, fruits, and other food crops for the family.
 Kitchen gardens can help us in the recycling of household waste especially when a
compost pit is developed.
 A kitchen garden is an integrated system that comprises the family house, a recreational
area, and a garden producing a variety of foods including vegetables, fruits, and
medicinal plants for home consumption or sale.
 The kitchen garden provides an opportunity to farm women and family members to earn
money and engage themselves in work along with proper utilization of place and water.
13. Define health-based intervention.
14. What are the types of health-based intervention?
15. What do you mean by immunization?
16. Name use of vaccination.
17. List the IAP recommendation vaccination.
18. Write on the importance of safe drinking water, and sanitation.
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1. Mention the benefits of safe water drinking.

2. What are the basic principles of safe water drinking?
3. Write the safe drinking water guidelines.
4. Define malnutrition.
5. What is kitchen gardening?
6. Write the benefits of kitchens garden.
13.12: GLOSSARY
Interventions: The act of interfering with the outcome or course, especially of a condition or
process.
Sanitation: Conditions relating to public health, especially the provision of clean drinking
water and adequate sewage disposal.
Epidemiology: It is a method used to find the causes of health outcomes and diseases in
populations.
Mammography: A technique using X-rays to diagnose and locate tumors of the breasts.
Pentavalent: Having a valence of five, (containing Diphtheria+Pertussis+Tetanus+Hepatitis

B+Hib).
Availability: Refers to both sufficient quantities and reliability of service provisions.
Adequacy: Refers to both the quality and quantity of water.
Reliability: Refers to the continuity of the service provider for the current and future
generations.
Acceptability: Refers to the esthetic value of water – the acceptable appearance, taste, and
odor of water.
Accessibility: To water refers to the accessibility to a reliable supply of water continuously
close to the point of demand.
Malnutrition: Deficiencies or excesses in nutrient intake, imbalance of essential nutrients, or
impaired nutrient utilization.
Kitchen garden: This is the growing of fruits and vegetables in the backyard of the house by
using kitchen wastewater.
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13.13: REFERENCES
1. Andres L, Briceno B, Chase C, Echenique J A. 2014. “Sanitation and Externalities:
Evidence from Early Childhood Health in Rural India.” Policy Research Working Paper
6737, World Bank, Washington.
2. Brown J, Cairncross S, Ensink J. 2013. “Water, Sanitation, Hygiene and Enteric
Infections in Children.” Archives of Disease in Childhood
3. Clasen T, Alexander K, Sinclair D, Boisson S, Peletz R., others. 2005. “Interventions
to Improve Water Quality for Preventing Diarrhoea (Review).
4. IAP Guidebook on Immunization 2020-2021.
5. Immunization Handbook for Medical Officers.
6. Jana, H. (2015). Kitchen gardening for nutritional security. Rashtriya Krishi, 10(2):
13-16.
7. Srilakshmi B (2010), textbook of Nutrition Science, New Age International
Publication, New Delhi.
8. WHO (World Health Organization) and UNICEF (United Nations Children’s Fund).
2010. Progress on Drinking Water and Sanitation: 2010 Update. Geneva: WHO.
1. Awasthi, N., Sahu, A., Chandrakala and Singh, K. (2016). Household food security
through kitchen garden: A practically workable step by KVKs in U.P. State. Adv. Soc.
Res., 2(1): 4951.
th
2. B Srilakshmi (2019), Textbook of Dietetics - Multi Colour 8 Edition, New Age
3. Chayal, K., Dhaka, B.L., Poonia, M.K. and Bairwa, R.K. (2013). Improving nutritional
security through kitchen gardening in rural areas. Asian J. Home Sci., 8 (2): 607-609.
4. Immunization Handbook for Medical Officers.
5. Waddington H, Snilstveit B, White H, Fewtrell L. 2009. “Water, Sanitation and Hygiene
Interventions to Combat Childhood Diarrhoea in Developing Countries.” Synthetic
Review 001, International Initiative for Impact Evaluation, New Delhi, India.
6. WHO (World Health Organization) and UNICEF (United Nations Children’s Fund). 2012.
Rapid Assessment of Drinking-Water Quality (RADWQ): A Handbook for
Implementation. Geneva: WHO.
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UNIT – 14: FOOD-BASED INTERVENTIONS
14.0: OBJECTIVES
14.1: INTRODUCTION
14.2: FOOD FORTIFICATION
14.3: DIETARY DIVERSIFICATION
14.4: SUPPLEMENTARY FEEDING
14.5: PREVENTION AND MANAGEMENT OF DIARRHEAL DISEASES
14.6: SUMMARY
14.9: GLOSSARY
14.10: REFERENCES
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14.0: OBJECTIVES

 Understand the different ways of food-based intervention and its uses.
 Know the method of food fortification and its importance.
 Discuss the dietary diversification importance and its application.
 Describe the purpose of supplementary feeding and nutrition supplementation
programs in India.
 Learn prevention and management of diarrheal diseases to control malnutrition and
mortality.
14.1: INTRODUCTION
The Food and Agriculture Organization promotes nutrition interventions considering

food as the basis for action, given the strategic role of food and the agricultural sector to
improve food security for the community; thus, a large number of people, especially the poor,
who participate directly or indirectly in agricultural activities can obtain benefits from its
multifunctional character. Food-based nutrition interventions have the purpose of improving
food production and availability, processing and conservation, supply and commercialization,
as well as access and food consumption. The basis of this focus is community and local
government participation in the planning, execution, supervision, and evaluation of specific
interventions.
Food-based nutrition interventions include the development of community gardens

and farms in urban and rural areas; hydroponic gardens and other related initiatives in urban
and periurban agriculture; as well as the promotion of traditional crops with nutritional value
and the development of small agro-industries. Food-based nutrition interventions can be
implemented to improve the food supply in the street and itinerant markets, town squares,
rural markets, and street food sales. In all food-based interventions, food safety and quality
control must be taken into consideration throughout the food chain. The interventions in
nutrition education increase the family's capacity to improve access to and consumption of
food. Food-based dietary guidelines and nutrition education in schools are highlighted, as
well as the utilization of school gardens.
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14.1.0: Food Production and Conservation:
In food-based nutrition interventions, family and community gardens and farms –

conceived as food production systems that contribute to improving the food security of rural
and urban households – are highlighted. These increase the supply and consumption of
complementary foods such as roots, tubers, legumes, fruits and vegetables, products of
animal origin, medicinal plants, spices, and others, during the whole year round, resulting in
food reserves that can be stored and processed and any surplus sold, thus contributing to the
household economy as well as helps improves the nutritional status of the family and
community. These initiatives could be the responsibility of the whole family group or the
women, in which case one can have a greater certainty of the use of the benefits obtained to
improve household food security.
It is a low-cost technology, easy to learn, needs little drinking water or rain, and
allows family training, especially for women, in the production and consumption of fresh and
safe vegetables. Moreover, it promotes self-employment, the development of micro-
enterprises, and the use of the scarce resources of the poor urban and periurban population.
One must mention the importance of the production and consumption of traditional under-
exploited crops with a nutritional value that has been abandoned in favor of commercial
crops.
From the nutritional point of view, the under-exploited crops increase the availability
of energy and nutrients and provide a balanced diet composition, improving food security in
low-income rural and urban households. Moreover, these crops can be cultivated in small
family farms with minimum costs of water and fertilizers, on land not appropriate for other
crops. Furthermore, small producers and women obtain economic benefits from these
income-generating activities.
14.1.1: Food Supply and Commercialization:
The channels of food supply are extremely important to improve the availability of
and access to foods on the part of the community, to facilitate the commercialization by the
small producers and the rural agro-industry. Several related interventions can be made with
street and itinerant markets, town squares, and rural markets as well as food street vendors.
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The function of the informal trade sector in urban areas of low income is a significant
aspect to be considered in the food supply chain and generating income for poor families.
This requires a positive attitude by municipal authorities and special programs oriented to
facilitate the commercialization of food products originating in these sectors.
Food safety and quality control throughout the food chain must be taken into account
in all food-based interventions. In this regard, it is necessary to strengthen both the control
systems at the municipal level and the training of producers and food handlers, as well as
address consumer education.
14.1.2: Food Access and Consumption:
The main objective of the intervention in food and nutrition education is to increase
the capacity of households to take advantage of existing resources to improve their access to
and consumption of a variety of safe and quality food to guarantee nutritional well-being.
To plan an intervention in food and nutrition education, it is necessary to identify

nutritional problems, their causes, and the affected population; perform an educational
diagnosis to analyze the elements which influence the conducts and practices wished to be
modified; formulate the objectives in a clear, precise, measurable way and a specific period;
select the contents, learning experiences, educational messages, and media; and, finally, to
elaborate the evaluation system.
The food-based dietary guidelines constitute a strategy to comply with the nutritional
goals of the population in support of the food and nutrition policies of the countries and
public education in general. These guidelines are comprehensible messages that promote the
benefits of healthy nutrition habits for the population to improve the epidemiological profile.
In its participative and multi-sector preparation, the nutrition situation, and social, cultural,
economic, environmental, and agricultural factors related to the adequate availability and use
of food are considered.
School children are part of a priority group for nutrition education since schools and
their programs represent an ideal opportunity to perform joint and ample nutritional activities
with the participation of parents and the community. School education allows the orientation
of school children to determine healthy diets and lifestyles throughout the life cycle,
reinforcing their knowledge during the school education process.
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Nutrition education in rural and urban schools is more effective if means of support
are available associated with practical activities related to food and nutrition. In this sense,
the implementation of school gardens is a tool used as a science laboratory to develop
knowledge, experience, and practical activities on agriculture, food and nutrition,
commercialization, environmental issues, science, and life skills.
14.2: FOOD FORTIFICATION
Food fortification (FF) is defined as the addition of one or more essential nutrients to
a food, whether or not it is normally contained in the food, to prevent or correct a
demonstrated deficiency of one or more nutrients in the population or specific population
groups. Fortification, therefore, differs from enrichment, which is the process of restoring the
nutrients to a food removed during refinement or production.
Fortification commonly uses staple foods as vehicles to deliver micronutrients

generally lacking or not contained in sufficient concentration in the diet of a population and
has been practiced since the 1930s to target specific health conditions such as iodine
deficiency through the iodization of salt, and anemia through the fortification of cereals with
iron and vitamins, and neural tube defects through the fortification of wheat flour with folic
acid.
The several types of FF are distinct because different techniques and procedures are
used to fortify the target foods. Biofortification involves creating micronutrient-dense staple
crops using traditional breeding techniques and/or biotechnology. Using biotechnology
(genetic engineering) to biofortify staple crops is more modern and has gained much attention
in recent years. The most popular example of this approach is the transgenic 'Golden Rice'
containing twice the normal levels of iron and significant amounts of beta-carotene.
Microbial bio fortification involves using probiotic bacteria (mostly lactic acid
bacteria), which ferment to produce -carotene either in the foods we eat or directly in the
human intestine. Commercial and industrial fortification involves fortifying commercially
available products such as flour, rice, cooking oils, sauces, butter, etc. with micronutrients
and the process occurs during manufacturing. The home fortification consists of supplying
deficient populations with micronutrients in packages or tablets that can be added when
cooking/ consuming meals at home (basically a merger of supplements and fortification).
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14.2.0: Food fortification includes

 Bio-fortification.
 Microbial bio-fortification.
 Commercial and industrial fortification.
 Home fortification.
14.2.1: Problem Identification

To successfully develop and implement a FF program, a country needs to have a
clear understanding of the nature of the nutrition problem by collecting information on the
extent and severity of the problem, whether it affects different demographic groups,
implications, the commitment of government and producers for addressing the problem,
major causes, and resources available.
14.2.2: Bioavailability of Fortificants

Absorption of added nutrients, particularly iron and zinc, varies widely depending on
the fortificant used. The nature of the food vehicle, and/or the fortificant, may limit the
amount of fortificant that can be successfully added. Selection of the form of micronutrient to
be used as a fortifying agent requires consideration of the bioavailability, chemical, and
physical properties of both the fortifying agent and the food to be fortified.
14.2.3: Advantages and Limitations of Food Fortification

Being a food-based approach FF has several advantages over other interventions as it
does not necessitate a change in dietary patterns of the population, can deliver a significant
proportion of the recommended dietary allowances for several micronutrients continuously,
and does not call for individual compliance. It could often be dovetailed into the existing food
production and distribution system, and therefore, can be sustained over a long period.
If consumed on a regular and frequent basis, fortified foods will maintain body stores
of nutrients more efficiently and more effectively than will intermittent supplements.
Fortified foods are also better at lowering the risk of multiple deficiencies, an important
advantage to growing children who need a sustained supply of micronutrients for growth and
KSOU, Mysuru. 327

development, and to women of fertile age who need to enter periods of pregnancy and
lactation with adequate nutrient stores.
The limitations of FF are also well known: FF alone cannot correct micronutrient
deficiencies when large numbers of the targeted population, either because of poverty or
locality, have little or no access to the fortified food, when the level of micronutrient
deficiency is too severe, or when the concurrent presence of infections increases the
metabolic demand for micronutrients. In addition, various safety, technological and cost
considerations can also place constraints on FF interventions. Thus proper FF program
planning not only requires an assessment of its potential impact on the nutritional status of
the population but also of its feasibility in a given context. Further, it needs to be controlled
by appropriate legislation.
14.3: DIETARY DIVERSIFICATION
Dietary diversification interventions are interventions that change food consumption

at the household level, such as increasing the consumption of animal-source foods. In most
resource-poor settings, starch-based diets with limited access to meats, dairy, fruits, or
vegetables, are the dominant diets.
Diversifying diets is generally achieved through social and behavioral changes.

Besides the three types of food, nutrition education programs also provide cooking classes
and teach caregivers about the importance of meal frequency, hygiene, and even gardening.
Changing behaviors such as meal frequency and hygiene greatly contribute to children's
overall health. Teaching caregivers about gardening improves their access to diverse foods.
14.3.0: OBJECTIVE OF DIETARY DIVERSIFICATION:
 To increase the variety and quantity of nutrient-rich and micronutrient-rich foods in a

household’s diet.
 To decrease micronutrient deficiencies, including animal-source foods.
 To increase the production of nutrient-rich foods and improve access to diverse foods.
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Figure: 1- Importance of dietary diversification:
14.3.1: Nutrition and food biodiversity;

Food biodiversity is defined as the diversity of plants, animals, and other organisms
used as food, covering the genetic resources within species, between species, and provided by
ecosystems. Food biodiversity can be added by expanding one or more of the dietary
diversity food groups in their daily diet consumption.
14.3.2: When to measure dietary diversity;

The optimal time of year to measure the dietary diversity of households or individuals
depends on the objective of the survey or monitoring activity. The following table describes
several scenarios to assist potential users in planning surveys.
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Table 1: When to measure dietary diversity;

Objective Timing
Assessment of the typical diet In rural, agriculture-based communities In non-agriculture-
of households/ individuals based communities
 When food supplies are still
Any time of the year (if
adequate (may be up to 4-5 months
seasonality is not an
after the main harvest).
issue).
Looking at dietary diversity at
different points in the agricultural cycle
is one way of investigating the
seasonality of food security.
In many areas, there are important
seasonal differences in dietary patterns.
For a more complete assessment of the
usual diet, dietary diversity should be
measured during different seasons.
Assessment of the food During the period of greatest food shortage, such as
security situation in rural, immediately before the harvest or immediately after
agriculture-based emergencies or natural disasters.
communities  This may also serve as a baseline for monitoring change
due to an intervention or for investigating seasonality.
Assessment of the food At the moment of concern identify a possible food security
security situation in non- problem.
agricultural communities  May also serve as a baseline for monitoring changes
due to an intervention
Monitoring of food Repeated measures to assess the impact of the intervention on
security/nutrition programs the quality of the diet, were conducted at the same time of
or agricultural interventions year as the baseline (to avoid interference due to seasonal
such as crop and livelihood differences).
diversification
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14.3.3: Suggested Actions for Dietary Diversification

 Prioritize actions on social behavior change communication specifically home
contacts- Appropriate complementary feeding with quality, quantity, and frequency-
Design Social Behaviour Change Communication (SBCC) program so that people
know what foods they should consume by age, sex, occupation, and physiological
status. Intensify Inter-Personal counseling through grass-root workers and volunteers.
 Nutrition across the food value chain- Preserve and protect nutrition during
harvesting, procurement, storage, transportation, and cooking; Technology,
infrastructure, and awareness.
 Address other intervening factors and Empower Women and girls- Address illness,
poor sanitation, and hygiene, intra-household disparities, and discriminations to
prevent diet dilution and increase consumption of energy and nutrient/micronutrient
intakes.
 Focus on food insecurity and malnutrition hot spots- Introduce special programs and
institutional mechanisms to address exclusion and focus on the most vulnerable
Villages, Sectors, and Blocks.
 Establish a Grid of naturally biofortified gardens- Promote Kitchen gardens and
naturally bio-fortified crops like drumsticks, amla, minor millets, enriched tubers, and
root, etc. in government-owned land: Linking with social safety net programs i.e.
MGNREGA (Mahatma Gandhi National Rural Employment Guarantee Act).
Dietary diversity as a measure of household food access and food consumption can be
triangulated with other food-related information to contribute towards providing a holistic
picture of the food and nutrition security status in a community or across a broader area.
Dietary diversity is increasingly included in food and nutrition security surveys to provide
indicators of household food access or individual dietary quality. Some examples of where
dietary diversity could be included in the context of food and nutrition security assessment
are:
 Baseline and impact assessment in the framework of nutrition and food security
programs.
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 National surveys.
 Surveillance systems.
 Monitoring and evaluation of programs and policies.
 Emergency or routine food security analyses.
 Phase classification for identifying emergencies.
14.4: SUPPLEMENTARY FEEDING
Supplementary feeding is the provision of food to the nutritionally or socially

vulnerable in addition to the general food distribution to treat or prevent malnutrition.
Provision of nutrients either in the form of food or as a tablet, capsule, syrup, or powder to
boost the nutritional content of the diet. Supplementary feeding may help food insecure and
vulnerable people by optimizing the nutritional value and adequacy of the diet, improving the
quality of life, and improving various health parameters of disadvantaged families. In low‐
and middle‐income countries (LMIC), the problems supplementary feeding aims to address
are entangled with poverty and deprivation, the programs are expensive and delivery is
complicated.
A dietary supplement, also known as a food supplement or nutritional supplement, is a

preparation intended to supplement the diet and provide nutrients, such as vitamins,
minerals, fiber, fatty acids, or amino acids that may be missing or may not be consumed in
sufficient quantities in a person’s diet. Nutritional supplements are consumed by a normal
or diseased individual with or without prescription by a physician or a dietician to
improve general well-being.
Dietary supplements may contain predigested and easily absorbable nutrients in

concentrated form. They may have foods, which have (nutritional foods) neutraceutical
foods. Some may be amylase-rich foods and some may contain mushrooms. Soybean or
milk protein is the main ingredient. Some may contain herbs or substances traditionally used
for well-being but scientifically might not have been proven.
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14.4.0: Purpose;
Nutritional supplements are used for many purposes. They can be added to the
diet to boost overall health and energy; provide immune system support and reduce the
risks of illness and age-related conditions; improve performance in athletic and mental
activities, and support the healing process during illness and disease. However, most of
these products are treated as food and not regulated as drugs.
14.4.1: Nutritional supplements are recommended to;

 Significantly increase in weight and height.
 Improvement in mental scores related to memory and attention,
particularly in the younger age group.
 Increase in total bone mineral content in the line with increased height and
weight of the children.
 Increase in bone fat-free mass and fat mass.
 Improvement in biochemical l status of some e micro round t rents such as
vitamins A, C, D, Riboflavin, and Folate.
14.4.2: Nutritional supplements are required by;

 People with nutrient deficiencies,
 Pregnant and lactating women,
 Newborn(Vitamin K),
 Those addicted to alcohol,
 Those recovering from Surgery, burns, injury, or illness,
 Vegans,
 People taking medications that interfere with the body’s use of nutrients,
 Those who have lactose intolerance(Calcium),
 Chronic drug consumers,
 Habitual dieters,
 Elderly people,
 Victims of infections like AIDS and
 Other wasting diseases.
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14.4.3: Dietary supplements are available in different forms;

 Tablets - Nutrients.
 Capsules- Lecithin, cod liver oil, vitamins, minerals.
 Powder supplements- Diet powders, energy powders, protein-rich, weight gain.
 Liquid supplements- Protein drinks, herbal extracts, liquid tonics.
 Nutrition bars-high density nutrition.
To get the most from the supplement or vitamins and minerals, supplements are to
be taken with food. An iron supplement should be taken with foods that assist in its
absorption such as meats, fish, or poultry or foods that contain Vitamin C.
Supplementary feeding programs are generally targeted to vulnerable individuals, for

example by the age of the child or the state of pregnancy or lactation of the mother. Targeting
of supplements is more often based on nutritional indicators than income, and may initially
be geographic - to clinics that distribute the supplementary food. School feeding is one
alternative to clinic-based feeding, although it lacks the potential synergism with health
services, and targets a different group (though both types may discriminate against the poor).
Only school-enrolled children will benefit from school feeding, although the availability of
subsidized meals may encourage the enrolment of children from poorer households.
14.4.4: Nutrition Supplementation Programs in India;
 Integrated Child Development Services Scheme (ICDS).

 Mid-day meal Programs (MDM).
 Special Nutrition Programs (SNP).
 Wheat-Based Nutrition Programs (WNP).
 Applied Nutrition Programs (ANP).
 Balwadi Nutrition Programs (BNP).
 National Nutritional Anaemia Prophylaxis Program (NNAPP).
 National Program for Prevention of Blindness due to Vitamin A Deficiency.
 National Goitre Control Program (NGCP).
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14.5: PREVENTION AND MANAGEMENT OF DIARRHEAL DISEASES
The number of stools normally passed in a day varies with an individual's diet and age.
When there is diarrhea, stools contain more water than usual-they are often called loose or
watery stools. They may also contain visible blood, in which case the illness is called
dysentery. Mothers usually know when their children have diarrhea. When diarrhea occurs,
mothers may say that the stools smell strong or pass noisily, as well as being loose and
watery. Talking to mothers often reveals one or more useful local definitions of diarrhea. For
practical purposes, diarrhea is defined as three or more loose or watery stools in a day (24
hours).
Diarrhea is most common in children, especially those between 6 months and 2 years of
age. It is also common in babies under the age of 6 months who are drinking cow's milk or
infant feeding formulas. Frequent passing of normal stools is not diarrhea Babies who are
taking only breast milk commonly have frequent soft stools; this is not diarrhea.
14.5.0: Acute and persistent diarrhea;
Diarrhea is classified as acute or persistent according to its duration. An episode of

diarrhea that lasts less than 2 weeks is acute diarrhea; diarrhea that lasts 2 weeks or longer is
persistent.
14.5.1: Why is diarrhea dangerous?
The two main dangers of diarrhea are death and malnutrition. Death from acute diarrhea
is most often caused by the loss of a large amount of water and salt from the body. This loss
is called dehydration. Another important cause of death is dysentery. Death from dysentery is
caused by damage to the intestine, systemic infection, and malnutrition. Severe diarrhea with
complications is most common in people with malnutrition.
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Diarrhea can also cause malnutrition and make existing malnutrition worse because:
 Nutrients are lost from the body.

 Nutrients are used to repair damaged tissue rather than for growth.
 A person with diarrhea may not be hungry.
 Mothers may not feed children normally while they have diarrhea, or even for some
days after the diarrhea is better.
To prevent malnutrition, children with diarrhea should be given food as soon as they will
eat, and should be given extra food after the diarrhea stops.
14.5.2: How does diarrhea cause dehydration?
The body normally takes in the water and salt it needs (input) through drinks and food. It
normally loses water and salt (output) through stools, urine, sweat, and breathing. When the
bowel is healthy, water and salt pass from the bowel into the blood. When there is diarrhea,
the bowel does not work normally. Less water and salt pass into the blood, and more pass
from the blood into the bowel. Thus, the amounts of water and salt passed in the stools are
greater than normal. This larger-than-normal loss of water and salt from the body can result
in dehydration. Dehydration occurs when the output of water and salt is greater than the
input. The more diarrhea stools a person passes, the more water and salt he or she loses.
Repeated vomiting, which often accompanies diarrhea, can also contribute to dehydration.
Dehydration occurs faster in infants and young children, in hot, dry climates, and when
there is a fever.
14.5.3: Treating a child who has diarrhea:
The most important parts of the treatment of diarrhea are:
 To prevent dehydration from occurring, if possible.

 To treat dehydration quickly if it does occur
 To feed the child.
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Figure: 2- Treatment for Diarrhoea
14.5.4: Prevention of dehydration:
Dehydration can usually be prevented in the home if the child drinks extra fluids as soon
as diarrhea starts. A child should be given one of the fluids recommended locally for home
treatment of diarrhea. These include oral rehydration salts (ORS) solution, food-based fluids
(such as soup, rice water, and yogurt drinks), and plain water. If possible, food-based fluids
should contain a small amount of salt. ORS solution can be used for both the prevention and
treatment of dehydration. If the child is under 6 months old and is not yet taking solid food,
ORS solution or water should be given rather than a food-based fluid.
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Figure: 3- Prevention and Treat for Acute Diarrhoea
14.5.5: Treatment of dehydration:
If dehydration occurs, the child should be taken to a community health worker or health
center for treatment. The best treatment for dehydration is oral therapy with a solution made
with ORS. ORS solution can be used alone to rehydrate 95% or more of patients with
dehydration. Patients with severe dehydration require rehydration with intravenous (IV)
fluids at first but should be given ORS solution in addition to IV fluids as soon as they can
drink. ORS solution should be used alone when the signs of severe dehydration are gone.
14.5.6: Feeding:
Feeding during diarrhea provides nutrients the child needs to grow and be strong, and
prevents weight loss. Fluids given to prevent or treat dehydration, such as the recommended
home fluid or ORS solution, do not provide the required nutrients; frequent feeding with
adequate amounts of nutritious food is essential. Breastfed children should be offered
breastfed frequently. Other children should receive their usual milk. Children of 6 months or
older (or infants who are already taking solid food) should frequently be offered small
amounts of nutritious, easily digestible food. After diarrhea has stopped, an extra meal should
be given each day for 2 weeks to help children regain the weight lost during the illness.
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14.5.7: Educating family members about the home treatment of a child who has
diarrhea:
Mothers and other family members can often treat children who have diarrhea with fluids
and foods that they have at home. Health workers can help by showing mothers how to do
this.
There are three rules for treating diarrhea in the home. Whenever a child gets diarrhea,
the mother (or any other family members who care for the child) should follow these rules.
Briefly, the rules are:
 Increase fluids
 Give the child plenty of food
 Take the child to a health worker if he or she is not getting better.
Mothers whose children are sick with diarrhea will be particularly interested in learning
about home treatment. When teaching them about the home treatment of diarrhea:
 Select an appropriate time. For example, the mother of a child who has diarrhea
should be taught how to treat diarrhea at home; information about prevention can be
given at another time when the child is healthy.
 Remember the community's beliefs about diarrhea and ways of treating it. Relate your
advice to current practices, and use words the mother will understand.
 Show the mother what to do (for example, show her how much fluid to give the child
after each stool).
 Use familiar teaching aids (for example, use common containers to demonstrate how
to mix ORS).
 Let the mother practice what she is learning while you watch. (For example, let her
give the fluid with a spoon while you watch.) This will help the mother to remember
what she has learned. It will also let you see whether she has learned correctly so that
you can provide extra help if necessary.
 Ask the mother to tell you, in her own words, things that she has learned but not
practiced, to be sure that she remembers. (For example, she can tell you what food she
will give and how often.).
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 Ask the mother whether she has any questions, and try to answer them. Ask her
whether she has any problems following your instructions.
 Listen to what she says and try to help her find a solution to the problems.
 Tell the mother what to expect (for example, how long it will take for her child to get
well).
14.6: SUMMARY
 Food-based nutrition interventions have the purpose of improving food production

and availability, processing and conservation, supply and commercialization, as well
as access and food consumption.
 Food-based nutrition interventions include the development of community gardens
and farms in urban and rural areas; hydroponic gardens and other related initiatives
in urban and periurban agriculture; as well as the promotion of traditional crops with
nutritional value and the development of small agro-industries.
 Food-based nutrition interventions can be implemented to improve the food supply in
the street and itinerant markets, town squares, rural markets, and street food sales.
 Nutrition education in rural and urban schools is more effective if means of support
are available associated with practical activities related to food and nutrition.
 Fortification, therefore, differs from enrichment, which is the process of restoring the
nutrients to a food removed during refinement or production.
 Microbial bio fortification involves using probiotic bacteria (mostly lactic acid
bacteria), which ferment to produce -carotene either in the foods we eat or directly
in the human intestine.
 Dietary diversification interventions are interventions that change food consumption
at the household level, such as increasing the consumption of animal-source foods.
 Diversifying diets is generally achieved through social and behavioral changes.
Besides the three types of food, nutrition education programs also provide cooking
classes and teach caregivers about the importance of meal frequency, hygiene, and
even gardening.
 Supplementary feeding is the provision of food to the nutritionally or socially
vulnerable in addition to the general food distribution to treat or prevent
malnutrition.
KSOU, Mysuru. 340

 Dietary supplements may contain predigested and easily absorbable nutrients in

concentrated form.
 Diarrhea is most common in children, especially those between 6 months and 2 years
of age. It is also common in babies under the age of 6 months who are drinking
cow's milk or infant feeding formulas.
19. Define food-based intervention.

20. What are the techniques used in food-based intervention?
21. Define food fortification.
22. Name the types of food fortification.
23. List the advantages and limitations of food fortification.
24. Define dietary diversification.
25. Mention the suggested actions for dietary diversification.
26. What is supplementary feeding?

27. What is the purpose of supplementary feeding?
28. Mention the different forms of dietary supplements available in the market.
29. List the nutrition supplementation programs in India.
30. Define diarrhea.
31. What are the times of diarrhea?
32. How to Prevention and treat dehydration.
14.9: GLOSSARY:
Nutritional Intervention: It is a set of actions intended to change a nutritional aspect in an

individual or population.
Food biodiversity: It is defined as the diversity of plants, animals, and other organisms used
as food.
Fortification: Fortification is the practice of deliberately increasing the content of one or

more micronutrients.
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Biofortification: it is the idea of breeding crops to increase their nutritional value.

Dietary diversity: it is the variety or the number of different food groups people eat over the
time given.
14.10: REFERENCES:
1. Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO
Expert Consultation. WHO Technical Report Series, No. 916. Geneva: World Health
Organization; 2003.
2. Food and Agriculture Organization/Ministerio de Educacioń/Institutio Nutricioń y
Tecnologıá de Alimentos (2003) Educacioń en alimentacioń y nutricioń para la
ensenãnza ba´sica. Proyecto de la FAO TCP/CHI/0065. Santiago de Chile: Oficina
Regional de la FAO para Ame´rica Latina y el Caribe; available at http://www.rlc.fao.
org/prior/segalim/accalim/educa.htm.
3. Gibney M, Walsh M, Goosens J. Personalized nutrition: paving the way to better
population health. In: Eggersdorfer M, Kraemer M, Vordaro JB, et al, eds. Good
nutrition: perspectives for the 21st century. Karger Publishers, 2016: 235-48.
4. Hatloy, A., Torheim, L. & Oshaug, A. 1998. Food variety--a good indicator of
nutritional adequacy of the diet? A case study from an urban area in Mali, West
Africa. European Journal of Clinical Nutrition 52(12):891-8.
5. Kennedy, G., Pedro, M.R., Seghieri, C., Nantel, G. & Brouwer, I. 2007. The dietary
diversity score is a useful indicator of micronutrient intake in non-breast-feeding
Filipino children. Journal of Nutrition 137: 1-6.
6. Mishra R.C. (2009) Health and Nutrition Education, New Delhi: A P H Publishing
House.
7. Shubhangini A. Joshi (Author), Nutrition and Dietetics, 3rd Edition, Tata Mcgraw
Hill Publishing Company Ltd, 2010.
8. Srilakshmi, (2011.), Dietetics, 2nd edition, New Age International (P) Ltd.,
Publishers, New Delhi-110 002, India.
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2. Food and Agriculture Organization/United Nations Development Programme (2003)
La huerta hidropońica popular. Santiago de Chile: Oficina Regional de la FAO para
Ame´rica .
3. FAO. 2010. Expert Consultation on Nutrition Indicators for Biodiversity 2. Food
consumption. FAO. Rome, Italy (available at http://www.fao.org/infoods/
biodiversity/index_en. STM).
4. Hoddinott, J. & Yohannes, Y. 2002. Dietary diversity as a food security indicator.
FANTA 2002, Washington DC. (available at http://www.aed.org/Health/upload/
dietary diversity.pdf)
5. Latham, M. 1997. Human Nutrition in the Developing World. Food and Agriculture
Organization of the United Nations. Rome, Italy.
6. Mirmiran, P., Azadbakht, L., Esmaillzadeh, A. & Azizi, F. 2004. Dietary diversity
score in adolescents- a good indicator of the nutritional adequacy of diets: Tehran
lipid and glucose study. Asia Pacific Journal of Clinical Nutrition 13(1): 56-60.
7. Shubhangini A Joshi (2021), textbook of Nutrition and Dietetics, 5th Edition,
McGraw Hill Publishers, New York City (USA).
8. Swindale A. & Bilinsky, P. 2006. Household dietary diversity score (HDDS) for
measurement of household food access: indicator guide, Version 2. Food and
Nutrition Technical Assistance Project, Academy for Educational Development,
Washington, D.C.
9. Townsend, Carolyn E. & Roth, Ruth A (2003): Nutrition and Diet Therapy 8th ed.,
Delmar Publishers, Albany, USA.,
10. WHO. 2010. Indicators for assessing infant and young child feeding practices. Part 2
Measurement. Geneva; WHO. Available at: http://www.who.int/nutrition/
publications/infantfeeding/9789241596664/en/index.htm.
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UNIT-15: NUTRITION EDUCATION INTERVENTIONS
15.0: OBJECTIVES
15.1: INTRODUCTION
15.2: GROWTH MONITORING, PROMOTION
15.3: HEALTH AND NUTRITION-RELATED BEHAVIORAL CHANGE IN
THE COMMUNITY
15.4: ROLE OF COMMUNITY IN NUTRITION AND HEALTH
PROGRAMME
15.5: SUMMARY
15.8: GLOSSARY
15.9: REFERENCES
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15.0: OBJECTIVES

 Know the importance and goals of nutrition intervention education.
 Discuss the growth monitoring promotion process and its objectives.
 Understand health and nutrition-related behavioral change in the community.
 Explain the role of the community in nutrition and health program.
15.1: INTRODUCTION
The nutrition education intervention is specifically aimed at improving the dietary

intake of families and young children through nutrition and health education. The nutrition
intervention is the third step in the Nutrition Care Process and it involves both planning and
implementing an intervention to improve the patient’s nutritional health outcome, specifically
targeted at the nutrition diagnosis. Different types of intervention include food fortification,
supplementation, and behavioral and regulatory interventions which have an impact on
nutrition outcomes. Interventions should be specific - stating what, where, when, and how.
The goal of the intervention should be "fixing" the nutrition diagnosis, addressing the root
cause (or etiology) of the nutrition diagnosis, and reducing the signs/symptoms.
The importance of good nutrition throughout all life stages is well established and a
poor nutritional intake has implications for the development of many health issues including
non-communicable diseases such as cancers, cardiovascular diseases, and stroke. Many diets-
and lifestyle-related health issues such as diabetes, hypertension, obesity, and other
cardiovascular disease risk factors, which were previously seen developing in middle-aged
people, are now being seen in young people with increasing frequency.
Successful nutrition intervention should also include content and teaching strategies
that are developmentally appropriate for the community and address changes in the
environment. Fun and interesting health and nutrition education activities will increase the
community people's attention and motivation to learn and consequently change their health
and dietary practices. In addition, changes in the physical environment (i.e. the community
system) are conducive to promoting positive behavioral outcomes related to nutrition in the
community.
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Nutrition education intervention should include information on physical activity in

addition to nutrition. In recognition of the importance of physical activity on health and the
prevention of disease, the Dietary Guidelines for Americans recommend being physically
active each day. Regular physical activity sustains the ability of older adults to live
independently, and benefits individuals with arthritis and those with depression and anxiety.
It may reduce the risk of cognitive decline in older adults, and is effective in helping to
manage many chronic diseases.
Nutrition Education Intervention Goals
 To create positive attitudes toward good nutrition and physical activity and
motivate improved nutrition and lifestyle practices conducive to promoting
and maintaining the best attainable level of wellness for an individual.
 To provide adequate knowledge and skills necessary for critical thinking
regarding diet and health so the individual can make healthy food choices
from an increasingly complex food supply.
 To assist the individual to identify resources for continuing access to sound
food and nutrition information.
Nutrition Education Intervention Content:
The Dietary Guidelines, which include maintenance of a healthy weight, daily

physical activity, food safety, and moderation of alcohol intake, should serve as the
framework for all nutrition education activities.
A nutrition education program makes available information and guidance about:
 Food, including the kinds and amounts of food that are required to meet one's daily
nutritional needs.
 Nutrition includes the combination of processes by which the body receives
substances necessary for the maintenance of its functions and the growth and renewal
of its components, i.e., ingestion, digestion, absorption, metabolism, and elimination.
 Behavioral practices, including the factors which influence one's eating and food
preparation habits.
 Consumer issues, including the management of food purchasing power to obtain
maximum food value for the money spent.
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 Information on physical activity

 Information on the roles of nutrition and physical activity in maintaining health and
independence, and preventing or managing chronic diseases such as diabetes, heart
disease, high blood pressure, osteoporosis, and arthritis.
Nutrition Education Intervention Activities:
Nutrition education consists of activities that provide visual and verbal information
and instruction to participants or participants and caregivers in a group or individual setting.
The minimum length of one nutrition education presentation is five minutes. Examples of
nutrition education activities include presentations, cooking classes, food preparation
demonstrations, field trips, plays, panel discussions, planning and/or evaluating menus, food
tasting sessions, question and answer sessions, gardening, physical fitness programs, videos,
etc. For home-delivered participants, activities can include the distribution of educational
materials. When nutrition education is being provided by the nutrition program service
provider, all costs associated with the delivery of nutrition education services must be
budgeted and charged appropriately to that service.
15.2: GROWTH MONITORING, PROMOTION
Growth is the regular increase in size or weight of any living thing, whether it is a
plant, an animal, or a human being. Regular and continuous growth is the essence of health in
the early life of living objects.
Growth Monitoring Promotion (GMP) is an operational strategy for the promotion of

health, which enables mothers to visualize growth or the lack of it in their children and to
obtain specific relevant and practical guidance to assure continued regular growth and health
in their children. All growth monitoring activities aim to achieve behavioral changes in the
mother concerning child feeding, an appropriate response to illness, and an understanding of
the various factors which influence the growth and development of the child and the adoption
of methods in the community to promote optimal health.
Objectives of (GMP):
 To detect early growth faltering.
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 To promote optimal growth through effective nutrition and health education.

 To create awareness about growth amongst mothers of children.
 To enhance the delivery of primary health care intervention.
 To identify those at risk for malnutrition and to provide appropriate services to them.
Growth Charting:
A variety of anthropometric measures can be used to assess child growth. Among the
most studied are weight, height, mid-upper arm circumference, chest circumference, and head
circumference. Careful analysis of these has led to the conclusion that weight for age is one
of the most suitable parameters for measuring a child's growth at the field level. It is an easy
practical and suitable method for growth monitoring. The weight for the age curve is
regarded as being very sensitive to change.
Description of the intervention:

Growth monitoring and promotion (GMP) comprises:
 Measurement (the regular recording of a child's weight and sometimes their height);
 Assessment (plotting weight against age or weight against height on a growth chart;
 Analysis (interpreting the growth pattern of the child);
 Action related to the analysis (for example, counseling, providing nutritional
supplements, or examining the child for disease).
Process of Intervention:
The benefit of growth monitoring and promotion is thought to be mainly due to two
mechanisms: one is best summarised as the 'detecting a problem' mechanism, and the second
as the 'vehicle for health promotion' mechanism.
Detecting a problem:
The weighing of children and detection of faltering growth shows there is a problem
in an individual child. The health workers respond with targeted promotion activities based
on the growth status, including providing tailored counseling (such as appropriate feeding),
providing nutritional supplements, detecting and treating common diseases (such as vitamin
D deficient rickets, anemia, diarrhea, respiratory infection) and making referrals to health
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providers if needed. Such benefits could be detected in both individually randomized and
cluster-randomized designs.
Providing a vehicle for health and nutrition promotion:
The process of measuring is thought to provide a focus for discussing the importance
of nutrition and the relationship between nutrition and health. The interaction between health
workers and mothers is expected to raise maternal awareness and knowledge of childcare
practice leading to changes in health behavior. Moreover, it is expected to build a good
relationship between health workers and mothers to encourage the use of preventive and
curative health services. Such benefits are related to the package of care and the social
process occurring at a clinic, so would only be measurable in cluster-randomized trials.
Logic model and outcomes:
Figure 1 provides a logic model for GMP.
Figure 1: A logic framework for growth monitoring and promotion
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Substantive outcomes:
GMP aims to improve the nutritional status of children, and ultimately to reduce
mortality and morbidity in children under five years. However, GMP frequently meshes with
a series of other child health services. Demonstrating the contribution of GMP to reducing
child mortality in isolation from other interventions is therefore likely to be complicated.
However, it seems reasonable to expect to be able to identify, through properly controlled
trials, an effect on nutrition.
Intermediate outcomes:
The implementation of GMP can be expected to improve both mothers' knowledge of

nutrition and child care, with consequential improvements in a mother's health behavior, such
as her feeding practice. It can also be expected to improve health care providers' performance
concerning nutrition counseling, identification of faltering, and taking appropriate action.
GMP may reassure mothers, and so their satisfaction with the service increases, and
the use of health services is encouraged. These outcomes are sought. On the other hand, GMP
might make mothers anxious about whether their baby is growing well, in particular when
faltering is detected. In addition, a lack of effective communication between health care
providers and mothers could make mothers unwilling to make use of health services,
adversely impacting care, for example, reducing the uptake and coverage of vaccines.
Mothers' perceptions of GMP, therefore, need to be ascertained when evaluating the
effectiveness of GMP.
15.3: HEALTH AND NUTRITION-RELATED BEHAVIORAL CHANGE IN THE

COMMUNITY
Health-related behaviors:
Health-related behaviors such as poor diet, physical inactivity, and smoking are major
contributors to a range of disorders including obesity, metabolic syndrome, type - 2 diabetes,
and cardiovascular disease. Promoting sustainable change in these behaviors is however a
seemingly intractable public health problem.
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People's behavior influences health, for example, in the prevention, early detection,
and treatment of disease, the management of illness, and the optimization of healthcare
professionals' behaviors. Behaviors are part of a system of behaviors within and between
people in that any one behavior is influenced by others. Methods for changing behavior may
be aimed at individuals, organizations, communities, and/or populations and at changing
different influences on behavior, e.g., motivation, capability, and the environment. A
framework that encapsulates these influences is the Behavior Change Wheel, which links an
understanding of behavior in its context with methods to change behavior. Within this
framework, methods are conceptualized at three levels: policies that represent high-level
societal and organizational decisions, interventions that are more direct methods to change
behavior, and behavior change techniques that are the smallest components that on their own
have the potential to change behavior. To provide intervention designers with a systematic
method to select the policies, interventions, and/or techniques relevant to their context, a set
of criteria can be used to help select intervention methods that are likely to be implemented
and effective. One such set is the “APEASE” criteria: affordability, practicability,
effectiveness, acceptability, safety, and equity.
Health behaviors refer to any behaviors that impact people's physical and mental
health and quality of life. "Behavior" can be defined as "anything a person does in response
to internal or external events. Actions may be overt (motor or verbal) and directly measurable
or, covert (activities not viewable but involving voluntary muscles) and indirectly
measurable; behaviors are physical events that occur in the body and are controlled by the
brain”. Behaviors are part of a system in that any given behavior is influenced by other
behaviors of the same or other individuals. Individual behaviors (e.g., lighting up a cigarette
or eating an energy-dense snack) are often recurring and thus better described as “behavior
patterns” (e.g., smoking, overeating) characterized by aggregated measures such as
frequency, duration, intensity, or volume of consumption. Behaviors are dynamic in that not
only do they interact (positively and negatively) with each other, but these relationships
change over time.
Three types of behavior are related to population health: behaviors that contribute
to the prevention of disease, behaviors that involve care-seeking and adherence to treatment,
and behaviors that relate to the delivery of healthcare. For behaviors to translate into
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population health they must be maintained over the long run and factors influencing
maintenance may differ from those influencing initiation of change.
Tobacco smoking, excessive alcohol consumption, physical inactivity, and unhealthy

eating are leading contributors to preventable premature death and ill health in high-income
groups. Historically, the overall burden of disease in low-income groups is mainly attributed
to infectious diseases as opposed to non-communicable diseases, such as cancer, stroke, heart
disease, respiratory disease, and liver disease. However, due to the increased prevalence of
smoking, alcohol consumption, and obesity, low-income groups have begun to face a huge
combined burden from both non-communicable and infectious diseases. In addition to non-
communicable diseases, the risks of infectious diseases such as HIV/AIDS can also be
reduced or completely prevented by behavior change, such as by using a condom.
Frameworks for Behavior Change:
Behavior change can be aimed at different levels, including individual, organizational,

community, and population levels, and any intervention delivered at one level can impact
other levels. The most effective interventions are those that target several levels
simultaneously and consistently. There are a variety of types of methods to bring about
behavior change. The effective behavior change interventions and recommendations for
practice at population, community, and individual levels identified evidence-based principles
underlying effective behavior change.
These are;
 Knowledge and outcome expectancies (improving people’s knowledge about the
health consequences of their behaviors).
 Personal relevance (drawing people’s attention to what health behavior change would
mean for them).
 Positive affective attitudes (promoting positive feelings about behavior change).
 Descriptive norms (increasing the visibility of positive health behaviors in the social
environment).
 Subjective norms (improving social approval of positive health behaviors).
 Personal and moral norms (promoting personal commitments to behavior change).
 Self-efficacy (increasing people’s belief in their ability to change their behaviors.)
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 Intention/Goal setting and the formation of concrete plans (helping people set goals
and form plans on how to achieve them).
 Behavioral contracts (facilitating that people share their plans and goals with others).
 Social relationships (drawing attention to the social influences on health behaviors).
 Relapse prevention (helping people develop skills to cope with difficult situations).
Nutrition and Behavior:

Recently, knowledge from three different lines has together illuminated the complex
interactions between nutrition and related environmental factors, on one hand, and behavior
on the other hand. The three advancing areas are the behavioral sciences, knowledge of the
effects of specific nutrients on brain function, and the study of gross malnutrition in
underdeveloped regions of the world and its impacts on behavior.
The study of human behavior is one of the major advances of the 20th century starting
with Freud’s discovery of the importance of early traumatic experiences in the development
of neurotic disorders in adulthood. He tried to bring to understanding the interaction between
nature and nurture i.e. to recognize the multiple determinants of human behavior ranging
from genetic to environmental.
As the above developments were being made, in the understanding of behavior,
important discoveries were being made in the field of nutrition. Goldberger was the first to
observe that a specific nutritional deficiency could cause marked behavioral abnormalities.
Through epidemiological studies, he discovered the causal relationship between a nicotinic
acid deficiency and deficiency pellagra, which is characterized clinically by diarrhea,
dementia, and dermatitis. This helped to lay the foundation for understanding the role of
specific nutritional factors in behavioral functions.
Although the behavioral effects of concurrent infantile malnutrition were recognized
early in populations living in poverty, it is only recently that the long-term effects of early
malnutrition have been identified. It has been concluded that early malnutrition is responsible
for long-term behavioral changes, many of which limit a child's ability to adapt successfully.
Diet affects our quality of life and impacts behavior affecting our emotions and
maybe even how we think for example hunger will cause discomfort, while a full stomach
brings contentment. From the beginning of recorded history right up through the present,
humans have believed that the food they eat can have a powerful effect on their behavior.
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Currently, thousands still believe that a type of diet or a particular nutrient can help to
achieve sexual, emotional, or cognitive equilibrium.
The area of nutrition and behavior is interdisciplinary in that, to provide objective data
and verify some of the claims, information is borrowed from various disciplines such as
anthropology, psychology, biochemistry, medicine, public health, and sociology. How or
what a person eats determines nutritional status, but our approach to behavior will consist of
far more than the behavior of eating. This includes looking at factors that determine food
selection, behavior, and how it affects diet selection. Global, cultural, and familial factors
may influence food preferences, and how income determines food choice.
There is a relationship between nutrition and behavior which affects our life, food
selection, emotions, and thoughts. Throughout history, numerous theories have been made
about nutrition and behavior. Nutrition and behavior are interdisciplinary. Scientific research
is essential in distinguishing fact from fiction when it comes to claims on nutrition and
behavior.
Concepts and Models in Nutrition and Behaviour:

The relationship between nutrition and behavior is circuitous i.e. nutrition affects,
modifies, or influences behavior e.g. affecting performance, but that behavior can be just as
powerful in determining nutritional status or diet quality. In most cases, the relationship
between nutrition and behavior is not as direct as it involves other variables. Behavior can
influence nutritional status or diet quality. For example
 A malnourished person is likely to be lethargic. An adequate diet is necessary for the
individual to exhibit a reasonable amount of activity therefore nutrition is affecting
active behavior. Severe malnutrition can greatly depress physical and cognitive
functioning.
 Conversely, an individual who participates in exercise and bodybuilding to regain
muscle tone may find themselves hungry more often. This means that the active
behavior is having a direct effect on the nutritional status of that individual i.e.
increase in energy intake as a result of an increase in physical activity.
 From a behavioral perspective, an attention-seeking individual tends to enjoy hot,
spicy foods like chili peppers.
 An insecure individual may starve themselves to fit into a group or join a sports team.
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 Individuals who have experienced happy childhoods may cook more unhealthy food.
 Skipping a meal such as breakfast can reduce a child’s attention span on a learning
task while substances such as caffeine, a natural ingredient of coffee but an additive to
certain soft drinks, will boost attention and arousal. In contrast, a high-starch meal
may serve to calm a stressed adult just as much through its perception as a portion of
comfort food as by its facilitating the release of neurotransmitters.
 An overweight or obese child may not be physically active at school which may be
due to bullying by peers the child may snack excessively, and spend more time
indoors, further leading to less activity.
Role of nutrition on behavior:

The brain-behavior connection:
In humans, changes in behavior are ultimately a result of changes in the functioning
of the central nervous system (CNS) i.e. whatever affects the brain affects behavior. Diet
exerts an effect on both the developing and mature brain. Constituents of the diet i.e.
Minerals, vitamins, and macronutrients have been shown to influence brain function.
Energy Intake and Mental Health:

Energy refers to the calorie content of food. It is derived from carbohydrates, protein,
fat, and alcohol found in foods and beverages. The human brain is metabolically very active
and uses about 20-30% of a person's energy intake at rest. Individuals who do not eat
adequate calories from food to meet their energy requirements will experience in mental
functioning. A hungry person may also experience a lack of energy or motivation
Chronic hunger and energy deprivation profoundly affect mood and responsiveness.
The body responds to energy deprivation by shitting or slowing down nonessential functions,
altering activity levels, hormonal levels, oxygen and nutrient transport, the body's ability to
fight infection, and many other bodily functions that directly or indirectly affect brain
function. People with consistently low energy intake often feel apathetic, sad, or hopeless.
Carbohydrates and Mental Health:

Carbohydrates significantly affect mood and behavior. Eating a meal high in
carbohydrates triggers the release of insulin in the body. Insulin helps let blood sugar into
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cells where it can be used for energy. In addition, as insulin levels rise, more tryptophan (an
amino acid) enters the brain. Tryptophan affects levels of neurotransmitters in the brain,
especially serotonin. Higher serotonin levels in the brain enhance mood and have a sedating
effect, promoting sleepiness. Some researchers claim that a high sugar intake causes
hyperactivity in children.
Proteins and mental health:
Protein intake and intake of individual amino acids can affect brain functioning and
mental health. Many of the neurotransmitters in the brain are made from amino acids. The
neurotransmitter dopamine is made from the amino-acid tyrosine. The transmitter serotonin is
made from tryptophan. If the needed amino acid is not available, levels of that particular
neurotransmitter in the brain will reduce and brain functioning and mood will be affected.
e.g. If there is a lack of tryptophan in the body, not enough serotonin will be produced, and
low brain levels of serotonin are associated with low mood and even aggression in some
individuals. On the other hand, some diseases can cause a build-up of certain amino acids in
the blood, leading to brain damage and mental defects. For E.g. a build-up of the amino-acids
phenylalanine in individuals with a disease called phenylketonuria can cause brain damage
and mental retardation.
Alcohol and mental health:
A high alcohol intake can interfere with normal sleep patterns and thus can affect
mood. A person who consumes large amounts of alcohol will meet their energy needs but not
their vitamin and mineral needs. In addition, extra amounts of certain vitamins are needed to
break down alcohol in the body, further contributing to nutrient deficiencies.
Behavioral Effects of Severe Malnutrition:
 Lower IQ scores and school performance has been reported in impoverished children
who experienced early clinical malnutrition.
 Behavioral symptoms of marasmus include irritability and apathy. Those of
kwashiorkor include anorexia and withdrawal, whimpering and monotonous crying.
 Lethargy and reduced activity are the most commonly observed in the two forms. This
reduced motor activity may help to isolate malnourished infants from their
environment, resulting in limited opportunities for learning and thereby depressing
mental development. Malnourished newborns may be poor in their taste organization,
low in social responsiveness, and not very adept at orienting to visual stimuli.
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Effects on children and adults:

Cognitive deficits:
Severe malnutrition before three years of age leads to low IQs (below 70) even after
two or more years of recovery. Malnutrition may have been confounded with poor parenting
(e.g. mothers being less sensitive, verbally communicative, emotionally involved, or
interested in their child's performance relative to their behavior with the unaffected child).
Motor delays:
Motor skills are delayed in children with PEM, although this is not always the case.
School-age children who are only mildly undernourished can have their activity level
reduced. High activity positively correlates with protein-calorie intake and vice-versa.
Behavioral problems:
A study done among children found that energy intake was positively associated with
observed happiness and leadership, and was negatively associated with observed anxiety.
Formerly malnourished children show less emotional control, are more distractible, have
lower emotional spans, and develop poorer relationships with their peers and their teachers.
Food insecure families have children who are rated as higher in hyperactivity and other
problematic behaviors.
Despite cultural differences in expectations for behavior, malnourished children
generally seem to have more behavioral problems than normal children e.g. being aggressive
and hyperactive at ages eight and eleven, and higher in conduct disorders and excessive
motor activity at age seventeen.
School performance:
Those who were malnourished during infancy tend to earn poor grades than matched
controls (those who were well nourished then), although it is not obvious. NB: there has not
been much research conducted on school-age children concerning the long-term effects of
malnutrition on their school performance.
Effects on Adults:
Adolescents from low-income households that experience food insufficiency report
higher levels of mild depression, suggesting that persistent food deprivations may affect
mental health. Lethargy and reduced activity are also observed. Apathy, social isolation, and
impairments in memory also occur. Decreases in activity, motivation, self-discipline, sex
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drive, and mental alertness with an increase in apathy, irritability, and moodiness are also
common.
Figure 2: Nutrition Social and Behavior Change Framework
Modifying nutrition-related behavior:
As you have read in the chapter on 'Self ', adolescence is a time when an individual
begins to question authority and tries to establish her/his status. Eating behavior is one of the
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mediums through which individuality may be expressed by adolescents. Thus, rejection of

routine home food (which may be healthy) and eating outside (not so healthy), sometimes to
conform to peer preferences, is not uncommon in adolescence.
It is easier for us to change our lifestyle and diet patterns if we are convinced that we
want to do so. What are how adolescents can modify their behavior? The next section tells us
more about how to adopt healthy dietary practices.
Limiting television viewing: Television viewing should be limited to about one or

two hours each day (this includes playing video games or using the computer). Watching
television does not use up many Calories and it encourages eating erratically since it is
common to eat while watching TV. Overeating and under-eating are common among those
who do it.
Healthy eating habits: Eat three balanced meals of average size each day, plus two
nutritious snacks. One must try not to skip meals.
Snacks: Snacks should be limited to two each day and they can include low-calorie
foods, such as raw fruits or vegetables. Avoid using high-calorie or high-fat foods for snacks,
especially potato chips, biscuits, and fried foods. Of course, favorite snacks can be consumed
once in a while, but this should not be made a habit.
Drinking water: Drinking four to six glasses of water each day, especially before
meals is a good habit. Water has no calories and it will create a feeling of fullness. Avoid
drinking soft drinks and fruit juices too frequently, as they are high in energy (150-170
calories per serving).
Diet journal: It helps to keep a weekly journal of food and beverage intake and also
of the amount of time that is spent watching television, playing video games, and exercising.
Recording body weight each week is good practice.
Exercise: This is essential for a healthy life. Participating in extracurricular activities

such as sports helps to keep activity levels high.
Some tips to increase physical activities include:
• Walk or ride a bicycle for short distances.
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• Use stairs instead of elevators in a building.
• Do regular exercise for 20-30 minutes, 3-4 times each week. This can include
walking, jogging, swimming, or bike riding. Playing games and sports, such as skipping rope,
hockey, basketball, volleyball, or football, and doing yoga are also advisable for all ages.
Substance use and abuse: Substance use and abuse in adolescence is a public health
problem of major significance and concern. The substances most widely abused by
adolescents are tobacco, alcohol, marijuana, and other addictive drugs. The abuse of drugs
and alcohol hurts the nutrition and health status of adolescents. Nutrition intervention,
support, and counseling would play a major role in the physical and psychosocial
rehabilitation process.
15.4: ROLE OF COMMUNITY IN NUTRITION AND HEALTH PROGRAMME
In the previous subunits, we have learned about health and nutrition-related

behavioral change in the community. It is not sufficient if we are aware of the detrimental
health coverage. We should also take steps to understand the different nutrition policies or
intervention programs prevailing, how they are helping to improve the community's nutrition
status etc. In this context, this unit will teach about what the nutrition intervention program is
all about and the role of various multi-sectorial approaches like agriculture, food technology,
and environmental sanitation and health in overcoming malnutrition.
The main objectives of this nutrition and health program are;
 Define and describe the need for nutrition intervention programs.

 Role of the nutrition intervention program in improving community health.
 Describe the influence of agriculture, food technology, and environmental
sanitation and health on the nutritional status of the community.
Nutrition Intervention Programmes:
Nutrition Intervention is defined as purposefully planned actions intended to positively

change a nutrition-related behavior, environmental condition, or aspect of health status for an
individual, target group, or the community at large.
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The purposes of nutrition intervention programs are to improve the nutritional and health
status of the community by:
 Stimulating and sustaining the production, availability, and consumption of more

nutritious foods.
 Ensure awareness of public health programs.
 Resolve or improve the nutrition diagnosis or nutrition problem by the provision of
supplementation and/or education.
 Promote proper food habits and healthy lifestyles.
 Reduce the prevalence of protein-energy malnutrition.
 Reduce the prevalence of micronutrient deficiency, particularly vitamin A, folic acid,
calcium, iron, and iodine, among vulnerable groups and
 Reduce over-consumption of fat, empty calories, sodium, and alcohol.
Nutrition intervention can be executed through any of these four domains:
Food and/or Nutrient Delivery: Individualized approach for Food or nutrient provision.
Nutrition Education: A formal process to instruct or train a person in a skill or to impart

knowledge to help persons voluntarily manage or modify food, nutrition, and physical
activity choices and behavior to maintain or improve health.
Nutrition Counselling: A supportive process, characterized by a collaborative counselor-

patient relationship, to establish food, nutrition, and physical activity priorities, goals, and
individualized action plans that acknowledge and foster responsibility for self-care to treat an
existing condition and promote health.
Coordination of Nutrition Care: Consultation with, referral to, or coordination of nutrition

care with other health care providers, institutions, or agencies that can assist in treating or
managing nutrition-related problems.
The nodal responsibility of providing optimal health to all rests with the Ministry of
Human Resource Development which encompasses Departments of Women and Child
Development, Agriculture, Food, Civil Supplies, Health, and Family Welfare, Rural
Development, Education, Environment and Finance each of which have an individual crucial
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role for providing a sustained growth in nutrition and health, through nutrition intervention
programs.
Thus, the Government serves to attain the objectives of nutrition intervention through
programs implemented through five-year plans, using any of the above-listed domains. The
five-year plan recommends specific nutritional goals to be achieved at the end of five years.
In previous years, the 10th five-year plan (2002-2007), 11th five-year plan (2007- 2012), and
12th five-year plan (2012-2017) were oriented towards achieving good health for all people,
especially the poor and underprivileged by advocating improvements in individual health
care, public health, sanitation, clean drinking water, access to food and knowledge of hygiene
and feeding practices.
The health outcome goals would be achieved by nutrition action at different levels which
include:
Strengthening nutrition in medical, paramedical, and agricultural education:
Eradication of micronutrient deficiencies, examining the social causes of malnutrition,

Nutritional feeding of infants and young children as a part of the medical and nursing
curriculum, nutrition advocacy, and education for agricultural students and scientists.
Training Programme for Health Personnel:
Hospital staff, health workers, and health counselors should be trained to address the
problems of malnutrition, low birth weight, breastfeeding, supplementary feeding, and
supplementation of vitamin A, iron, and folate.
Establishing Nutrition Information System in the Country:
To assess the outcome of nutritional programs a proper standardized management

information system (MIS) is set. The efficacy of various services offered by the National
Rural Health Mission, ICDS is monitored, mapped, and surveyed through MIS. National
Nutrition Monitoring Bureau (NNMB) undertakes diet and nutrition surveys to project the
state-wise nutritional status. It projects the status of diet-related chronic diseases in the
country to enable region-specific and nutrient-specific preventive strategies.
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National Family Health Survey (NFHS) provides nationwide data on undernutrition among
children less than 5 years and anemia among women and children.
District Level Health Survey (DLHS) covers all districts in a phased manner and projects
district-level nutrition and health scenario.
Strengthening Intersectional Co-ordination Mechanism:
A high-level inter-agency coordination mechanism is necessary to enable directions to the

concerned sectors. Regular coordination between Health and Family Welfare and Women
and Child Development departments is essential as these are the key sectors that implement
the largest health and nutrition programs in the country.
Enhancing Investment in Nutrition and Health: Investment in health programs is not an

expense rather, it fetches higher economic growth and overall development. Allocating
sufficient funds will enhance the efficiency of the nutrition programs and outcomes.
Building Institutional Capacity for Nutrition Action: The national institutes in the field of
nutrition have not expanded much and their structures have not widened. National Institute of
Nutrition, NNMB, Food and Nutrition departments of home sciences colleges, and Food and
Nutrition Board although have taken great strides, the population growth and severity of
malnutrition prevailing in the country demand a lot more from them.
The efforts and outcomes of all these components should be pooled together to
succeed in the nutrition intervention programs.
Through the past five-year plans, even though, the outcome was productive and has
achieved positive improvements in nutritional status, it is not sufficient enough to achieve a
disease-free society.
After 2017, the five-year plans have been replaced by NITI (National Institution for
Transforming India) Aayog, which was established in 2015, by the Government of India, to
achieve Sustainable Development Goals (SDG) with the involvement of State Governments.
Its initiatives include agricultural reforms, Indices measuring the state's performance in
health, skill development, education and water management, and overcoming poverty. All
these missions if integrated and put into action will overcome malnutrition.
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15.5: SUMMARY
 The nutrition education intervention was specifically aimed at improving the dietary
intake of families and young children through nutrition and health education.
 Successful nutrition intervention should also include content and teaching strategies
that are developmentally appropriate for the community and address changes in the
environment.
 Nutrition education consists of activities that provide visual and verbal information
and instruction to participants or participants and caregivers in a group or individual
setting.
 Growth is the regular increase in size or weight of any living thing, whether it is a
plant, an animal, or a human being. Regular and continuous growth is the essence of
health in the early life of living objects.
 Health-related behaviors such as poor diet, physical inactivity, and smoking are major
contributors to a range of disorders including obesity, metabolic syndrome, type - 2
diabetes, and cardiovascular disease.
 Promoting sustainable change in these behaviors is however a seemingly intractable
public health problem.
 Health behaviors refer to any behaviors that impact people's physical and mental
health and quality of life. "Behavior" can be defined as "anything a person does in
response to internal or external events.
 Recently, knowledge from three different lines has together illuminated the complex
interactions between nutrition and related environmental factors, on one hand, and
behavior on the other hand.
 Diet affects our quality of life and impacts behavior affecting our emotions and
maybe even how we think for example hunger will cause discomfort, while a full
stomach brings contentment.
 There is a relationship between nutrition and behavior which affects our life, food
selection, emotions, and thoughts. Throughout history, numerous theories have been
made about nutrition and behavior.
 The relationship between nutrition and behavior is circuitous i.e. nutrition affects,
modifies, or influences behavior e.g. affecting performance, but that behavior can be
just as powerful in determining nutritional status or diet quality.
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 Nutrition Intervention is defined as purposefully planned actions intended to

positively change a nutrition-related behavior, environmental condition, or aspect of
health status for an individual, target group, or the community at large.
 Its initiatives include agricultural reforms, Indices measuring the state's performance
in health, skill development, education and water management, and overcoming
poverty. All these missions if integrated and put into action will overcome
malnutrition.
1. Define nutrition intervention education.

2. What are the goals of nutrition intervention education?
3. Mention the nutrition education programs.
4. Write the different types of nutrition interventions.
5. What is growth monitoring promotion?
6. List the Objectives of GMP.
7. Name the outcomes of GMP.
8. Define health-related behaviors.

9. Describe the types of behavior that are related to population health.
10. Name the evidence-based principles in effective behavior change.
11. Define nutrition-related behavior.
12. Write the concepts and models in nutrition and behavior.
13. List the behavioral effects of severe malnutrition.
14. Mention objectives of nutrition health programs.
15.8: GLOSSARY
Nutrition intervention: It is a set of actions intended to change a nutritional aspect in an

individual or population.
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Nutritional supplements: These are any dietary supplement that is intended to provide
nutrients that may otherwise not be consumed in sufficient
quantities
Counseling: Counseling is a collaborative effort between the counselor and the client.
Ingestion: It is the process of taking food, drink, or another substance into the body by
swallowing.
Digestion: The process of breaking down large, insoluble molecules of food into smaller,
water-soluble molecules which can then be readily absorbed by the body.
Motivation: It is the process of motivating individuals to take action to achieve a goal.
PLEASE: Affordability, Practicability, Effectiveness, Acceptability, Safety, and Equity.
Interdisciplinary: Involving two or more academic, scientific, or artistic disciplines.
Hyperactivity: It refers to constant activity, being easily distracted, impulsiveness, inability
to concentrate, aggressiveness, and similar behaviors.
15.9: REFERENCES
1. Abraham, C., Good, A., Huedo-Medina, T., Warren, M., & Johnson, B. (2012).
*Reliability and utility of the SHARP Taxonomy of Behaviour Change Techniques.
EHPS 2012 abstracts. [http://dx.doi.org/10.1080/08870446.2012.707817]* Psychology
& Health, 27 (Supplement 1), 1–357.
3. Department of Health & Family Welfares (2008), Behaviour Change Communication
Strategy for NRHM in Uttar Pradesh, Government of Uttar Pradesh, Lucknow.
4. Kundu, K. (2008), Non-cognitive Determinants of Behaviour Change, in Behaviour
Change Communication Strategy for NRHM in Uttar Pradesh, op. cit.
5. Swaminathan, M (2007), Essentials of Food and Nutrition. An Advanced Textbook Vol.
I, the Bangalore Printing and Publishing Co. Ltd, Bangalore.
6. SPRING. 2017. Accelerating Behavior Change in Nutrition-Sensitive Agriculture Online
Training Course. Arlington, VA: Strengthening Partnerships, Results, and Innovations in
Nutrition Globally (SPRING) project. Available at https://www.spring-
nutrition.org/publications/training-materials/acceler...
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7. USAID. 2017. Multi-Sectoral Nutrition Strategy 2014–2025 Technical Guidance Brief:

Effective At-Scale Nutrition Social and Behavior Change Communication. Washington,
DC: U.S. Agency for International Development
1. Abraham, C., Kelly, M. P., West, R., & Michie, S. (2009). *The UK
National Institute for Health and Clinical Excellence Public Health Guidance on
behavior change: A brief
introduction[http://dx.doi.org/10.1080/13548500802537903]*. Psychology, Health,
and Medicine, 14(1), 1–8.
2. BMA. (2012). Behavior change, public health and the role of the state—
BMA position statement. London: British Medical Association.
3. Dombrowski, S. U., Sniehotta, F. F., Avenell, A., Johnston, M.,
MacLennan, G., & AraujoSoares, V. (2012). *Identifying active ingredients in
complex behavioral interventions for obese adults with obesity-related co-morbidities
or additional risk factors for comorbidities: A systematic
review[http://dx.doi.org/10.1080/17437199.2010.513298]*. Health Psychology
Review, 6(1), 7–32.
4. French, D. P., Olander, E. K., Chisholm, A., & Sharry, J. Mc. (2014).
*Which behavior change techniques are most effective at increasing older adults' self-
efficacy and physical activity behavior? A systematic
review[http://dx.doi.org/10.1007/s12160-014-9593-z]*. Annals of Behavioral
Medicine, 48, 225–234.
5. Mackee Neill (2008) Behaviour Change Communication Strategy for
NRHM, Uttar Pradesh, op. cit. (http://www.globalhealth.communication.org)
6. Pattanaik, B. K (1994) ‘Distance Education through Mass Media’- A Case
Study of Health Education” in Bandhu D. (ed) Distance Education in India, Vinod
Publishers & distributors, Jammu.
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UNIT- 16: NUTRITION EDUCATION
16.0: OBJECTIVES
16.1: INTRODUCTION
16.2: NUTRITION EDUCATION AND COUNSELING
16.3: DESIGNING AND COUNSELING PLANNING
16.4: APPROACHES, TOOLS, AND TECHNIQUES
16.5: NUTRITION EDUCATION/ COUNSELING PROGRAMMES
16.6: SUMMARY
16.7. GLOSSARY
16.8: CHECK YOUR PROGRESS -I
16.10: REFERENCES
16.11: REFERENCES TO FURTHER
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16.0: OBJECTIVES
After studying this unit you will be able to
 Describe the need and scope of nutrition education

 Understand the overall process of nutrition education
 Enumerate the criteria for designing nutrition education
16.1: INTRODUCTION
You have already been introduced to Food based and nutritional-based interventions.
Nutrition programs in promoting the nutrition and health status of people in the community.
It is very important to know about nutrition and health education. No nutrition and health
program can indeed be successful without the proper usage of approaches and methods that
effectively reach the beneficiaries. You need to understand certain concepts before studying
different types of approaches in Nutrition and Health education. The concepts that should
know to you are the meaning of health, health education, objectives of health education, the
meaning of nutrition, nutrition education, objectives of nutrition education,
In this unit, we will be studying the planning, implementation, and evaluation of the
nutrition education program. The fundamental objective of education in nutrition is to help
individuals to establish food habits and practices that are consistent with the nutritional needs
of the body and adapted to the cultural pattern and food resources of the area in which they
live. Nutrition education is not merely a process of transferring facts or information about the
nutritive value of foods, the role of food in preventing nutrient deficiency disorders, or
methods of food production, marketing, distribution, and preparation. Rather nutrition
education is concerned primarily with the creation and establishment of habits of all types of
food-related practices, but especially those associated with improvement in individuals’
patterns of food consumption.
Thus the design of nutrition education programs and the methodologies employed in
carrying them out have some distinctive characteristics. The program must be planned in a
manner that will motivate people to adopt intelligent daily food consumption practices
consistent with health but within the limits of available food and economic resources.
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16.2: NUTRITION EDUCATION AND COUNSELING
Nutrition education is a set of learning experiences designed to assist in healthy eating

choices and other nutrition-related behavior. It includes any combination of educational
strategies, accompanied by environmental supports, designed to facilitate voluntary adoption
of food choices and other food and nutrition-related behaviors conducive to health and well-
being. Nutrition education is delivered through multiple venues and involves activities at the
individual, community, and policy levels. Nutrition Education also critically looks at issues
such as food security, food literacy, and food sustainability.
Nutrition education presents general information related to health and nutrition,
often to groups in clinic waiting rooms or community settings. Educators may be trained
counselors or health volunteers who deliver prepared talks on specific topics, often using
visual aids. They should encourage clients to ask questions and direct them to additional
information as needed.
Principal Aim of Nutrition Education:
 To provide people with adequate information, skills, and motivation to procure and
consume appropriate diets.
Goals of Nutrition Education:
 To reinforce specific nutrition-related practices or behaviors to change habits that

contribute to poor health.
 To learn new nutrition information and to develop the attitudes; skills and
confidence that they need to improve their nutrition practices.
Objectives of Nutrition Education:
 To enhance knowledge of nutrition and metabolism and the application of such

knowledge to the maintenance of health and the treatment of disease.
 To share information with families and the broader community that encourages them
to teach their children about nutrition and provide nutritious meals for their families,
and positively impact the health of the community.
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Nutrition counseling is a two-way interaction through which a client and a trained

counselor interpret the results of a nutrition assessment, identify individual nutrition needs
and goals, discuss ways to meet those goals, and agree on the next steps. Nutrition counseling
aims to help clients understand important information about their health and focuses on
practical actions to address nutrition needs, as well as the benefits of behavior change.
Nutrition counselors may be nurses or other facility-based providers or community health
workers or volunteers.
Optimal counseling contributes to successful health and nutrition outcomes. Ideally,

counseling should be done in a place where the client feels comfortable and has privacy. This
may be more challenging in a busy health facility than in a community setting, but
adjustments can be made to improve the situation. Counselors should be trained to understand
and use support materials such as flipcharts, counseling cards, take-home brochures, data
collection forms, and referral forms effectively.
Ethical Principles for Counseling:
Upholding ethical standards is also essential for effective counseling.
 Provide accurate information: Clients should be able to trust that counselors’ words
and actions are truthful and reliable.
 Keep client information confidential: Clients need to know that counselors will
keep their information confidential except as needed for their treatment or recovery.
 Respect clients’ autonomy: Clients have the right to make their own decisions
without coercion.
 Keep clients’ interests in mind: Advise them based on professional assessment and
offer alternatives if you cannot help them.
 Not harm: Avoid any interventions that could harm or exploit clients emotionally,
financially, or medically.
 Be fair: Treat all clients fairly and without discrimination. Respect clients’ rights,
dignity, and individual difference.
The foundation of effective counseling is asking questions about the client's
symptoms and situation to be able to give appropriate information and support the client to
make healthy choices at home. Just telling people what to do does not mean that they will do
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it, because knowledge is not enough to change behavior. Counselors need to know not only
what messages are appropriate, but also how to prioritize those messages depending on the
client's needs and how to deliver them effectively in a short time. This requires practice and
experience. Different mnemonic devices have been developed to help counselors remember
the steps in counseling and guide sound techniques. These can also be used during training
role-plays and supervision and mentoring visits.
Tips for Effective Counseling:

 Do more listening than talking.
 Ask open-ended questions, not just questions clients can answer with
 “Yes” or “no.”
 Repeat what clients say to make sure you understood them correctly.
 Show interest in and empathy for clients’ problems and situations.
 Avoid judging clients.
 Listen to what clients think and respect their feelings, even if information may need
correction.
 Recognize and praise what clients are doing correctly.
 Suggest actions that are possible for clients given their situations.
 Give only a little bit of information at a time.
 Use simple language.
 Give suggestions, not commands.
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?
How have you been
feeling?
What have youbeen

eating?
How is your treatment

going?
What makes itdi

cult to do
(desired behavior)?
What/who can support

you to do
Figure -1: Graphical Show of Best Practices for Effective Counseling.
IMPORTANCE OF NUTRITION EDUCATION
1. It reinforces knowledge and corrects faulty concepts about nutrition

2. It allows individuals to evaluate the nutrition information he or she receives
3. Facilitates the best use of an individual's limited economic resources
4. It helps individuals to make judicious food choices for health and well-being.
For example;
 If family members learn the importance of child nutrition they can
promote the optimal development of their children
 Schoolchildren and adolescents, who are aware of healthy foods,
can adopt a practice that helps them to attain normal growth.
 For pregnant women, it helps in making the right food choices and
to deliver a normal birth weight baby.
PROCESS OF NUTRITION EDUCATION
As you all know communication plays a very important role in transmitting the
designed message to the target population. Communication is nothing but the exchange of
words and meanings. It is a two-way process of sending and receiving messages. Effective
communication occurs when there is a shared meaning. There must be a mutual
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understanding between the sender and the receiver for the transmission of ideas or
information to be successful. Effective communication may be defined as;
 Using language that is appropriate to others' level of understanding
 Making sure that others receive the information or the knowledge intended
 Develop a relationship with others
 Talking with others in a way that facilitates openness, honesty, and cooperation
 Providing feedback
16.3: DESIGNING AND COUNSELING PLANNING
Doing these things leads to increased understanding and effective communication

counseling among the members.
Communication involves four basic components
1. Sender / Communicator
2. Message
3. Receiver and
4. Feed back
SENDER / COMMUNICATOR
The sender is the transmitter of the message. Five factors influence the sender in any
communication he transmits.
1. Communication skills
2. Attitudes
3. Knowledge
4. Position in the social system
5. Culture
Communication skills, five verbal communication skills determine one ability to
transmit and receive messages. They are, sending skills, speaking and writing, receiving
skills, listening and reading. The extent of development of these skills helps to determine our
ability to communicate verbally. The effectiveness of communication is also determined by
our ability with nonverbal communication skills.
Attitude influences our communication in three ways. Attitude towards ourselves
determines how we conduct ourselves when we transmit messages to others. If the sender has
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a favorable self-attitude the receiver will note our self-confidence or if the sender has an
unfavorable self-attitude the receiver will note uneasiness.
Knowledge level has a bearing on our ability to communicate efficiently about the
subject. The position of the sender and the receiver in their respective social systems also
affect the nature of the communication. Each one of us occupies a position in the family,
work group, or community/organization to which we belong. We perceive those with whom
we communicate as occupying a similar, higher or lower position in their respective social
system. Our culture also influences our communication effectiveness. Communication is
more effective between persons with similar cultural backgrounds.
Message
Is what the sender attempts to transmit to his specified receiver. Every message has at
least two major aspects, content, and treatment. The content of the message includes the
assertions, arguments, appeals, and themes which the sender transmits to the receiver. The
treatment of the message is the arrangement or order of the content by the sender.
Receiver
The receiver must be able to interpret and respond to the transmitted messages. The
goal of communication is reached when the receiver accepts the sender’s message.
Feedback
Is the sender’s way of determining the effectiveness of his message? The receiver may
use the same channel for feedback as the sender used for the original message. Feedback
provides a method for eliminating miscommunication. It is most effective in a face-to-face
conversation where it can be used instantaneously.
The scheme for planning nutrition education consists of three phases namely;
 Formulation
 Implementation
 Evaluation
Phase-I: Planning:
Planning means giving shape and structure to the different elements involved in the
process of nutrition education. Here this phase includes processes such as setting the
objectives, identifying the target audience, designing messages, and choosing an appropriate
type of media for delivering the messages.
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Setting objectives:
The main objective is the improvement of the nutritional status of the target group
which can be identified through indicators of nutritional status. The nutritional objectives
include short-term and long-term strategies. The short-term strategy would be to improve the
feeding practices of infants and the long-term aims at improving the weight of children. The
program also aims at creating awareness among mothers about nutrition, by encouraging
them to improve food production, and availability of food and to utilize the health facilities.
Identifying target audience:
The target audience is the population with whom we communicate for bringing about
behavior change. Behavior change is very important for improving the health and nutritional
status of individuals. We often find that family members and the community influences a
person's behavior. For example, the elders in the family may take decisions about what food
should be given or should not be given to infants of other age groups. The target population,
therefore, consists of different groups such as a vulnerable group and a target group. Here for
example pregnant women will be the vulnerable population as well as the target audience.
But for vulnerable groups like 0-5 years old children, the target audience would be the
mothers and grandmothers. The audiences can be further divided into primary, secondary,
and tertiary audiences.
Primary audience – for example, mothers of young children
Secondary audience – health care providers, family members and friends, and popular figures
who can motivate them to change their behavior.
Tertiary audience – decision makers, financial supporters, and influential people in the
community who are capable of facilitating the communication process.
Designing messages:
The message is the formulation of an idea or concept to be transmitted to a specific
population (for example; educating pregnant and lactating mothers about the importance of
maintaining good nutritional status, prevention of anemia among children and adolescents
improving feeding practices of young children). Media is the channel of communication
through which the message is transmitted (for example; group discussion, demonstration,
etc). Support materials such as flip charts, puppet shows, and radio programs can also be
effectively used to transmit the designed messages.
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Elements of a message design:

The message which is designed for educating the community should have certain
essential elements. So that it will be easy for the communicator to make the target group
understand in a better way what he/she is trying to communicate. The essential elements
include; the content, design, persuasion, and choosing the type of media
Content:
Content is one of the important elements which include the problem identification,
target audience, solution, and required action. Based on this information the required message
has to be designed.
Design:
This involves the use of ideas, relevant language, and portrayal of characters which
facilitates the audiences to identify or relate with the character.
Persuasion:
It should be able to transmit the message without resulting in any confusion or doubt.
Memorability:
Reinforcing the ideas should minimize distraction. Repetition can be used as a
strategy to improve the memorability of the target group.
Choosing the media:
You know that the Media are the channels of communication through which messages
are transmitted. Nutrition/health information can be communicated through many channels to
increase awareness and assess the knowledge of different target populations.
Face-to-face interpersonal methods:
This involves direct interaction between the source and the receiver. Examples;
individual discussions, counseling sessions or group discussions, community meetings, and
events. This is considered the most effective method of communicating messages.
Mass media communication:
Such as newspapers, magazines, booklets, leaflets, charts, models, posters, radio,
television, and audio-visual aids like films and documentaries.
Traditional channels:
Folk media such as storytelling play-acting, a song with a message, hand or string
puppets and stick puppets.
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Face-to-face interpersonal methods:

This involves direct interaction between the source and the receiver. The use of
support materials will enhance the effectiveness of the process of transmission of messages.
The support materials could be in the form of printed material, and visual or audio-visual aids
can also be employed. This reinforces the oral communication between the educator and the
target audience. Interpersonal communication is a very effective method of studying
nutrition-related problems.
The main advantage of the face-to-face method is that it is possible to contact specific
groups; relevant advice can be designed, and problem-solving skills and reinforces
community participation. It also provides an opportunity for questions, discussions,
participation, and feedback. But the only limitation of this method is that it is slow for
spreading information in a population.
Mass media methods:
Through this method, a large number of people can be covered at a time. This
involves the use of technological devices such as the press, radio, films, television, etc to
transmit the designed message to the target group. The interaction between the source and the
receiver is mediated through visual images, printed material, or a combination of these. The
source and the receiver are never in direct contact with this method. The advantage of this
method is that it is a rapid method that helps to reach a large audience, and helps to motivate
and teach. Mass media alone cannot persuade people to change their deep-rooted attitudes is
the only limitation.
Traditional methods:
It is most prevalent in the community. The traditional media are considered the
familiar and more credible forms. Three different types of traditional or folk media include;
folk music, ballad forms of folk, and puppetry. Folk music exists in all languages and styles
in India. A ballad form of folk approach involves folk singing. Puppet shows are an effective
method of communication and are practiced in many cultures. Puppets are of different types
such as string puppets, rod puppets, shadow puppets, and hand puppets.
Advantages:
 It is culturally specific and the community can easily understand the message
 It is available to all at a very low cost
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 Flexible in adopting new themes

 It preserves and disseminates the tradition and culture of our ancestors in a lively
manner.
Phase-II: Implementation:
Here in this phase, the planned activities are carried out in the particular field.
Implementation involves three main aspects.
 Production of communication materials
 Training, designing, and conducting a training program
 Executing the communication intervention
Production of communication material:
The various aspects related to the production, distribution, and use of communication
material such as how much material is to be produced, distributed and use of a material such
as an amount produced, who produces, who uses them, how distributed methods of use, and
the total cost incurred for all these activities.
Designing an effective training program:
This is very essential to train the change agents (community educators) to educate
and communicate for behavior change among the target group. The designing and conducting
effective training program includes; training educators or change agents, establishing training
strategies, developing guidelines, and formulating a training plan.
a) Training of change agents
These could be Anganwadi workers, health workers, teachers, agriculture promoters,
or other persons from diverse sectors who should be trained in such a way that they become
familiar with the message content as well as the techniques used to communicate effectively.
They should be well informed of their role in the entire strategy.
b) Training strategy
The purpose is to define the overall context for training. They also decide on the
training of program implementers (supervisors), and influential people (physicians, NGO,
and other related personnel). At this stage, they should also establish the details about the
number of individuals to be trained, schedules and materials, and training of trainers.
c) Training guidelines
For training a community worker to train the community for improving nutritional
status or any nutrition-related issues she needs to know the following things;
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 The training should be directed to the performance of specific tasks-activities directed

toward solving nutrition-related problems
 Maximum participation by the trainees is important to increase the effectiveness.
 The training should be given in a community in which he/she will be working later.
 Refresher training at regular intervals is necessary to increase the effectiveness of
community workers and supervisors.
Plan of training program:
For planning any type of training program certain specific points must be considered
during planning. This includes;
 Assessing learning needs
 Defining learning objectives
 Deciding on content area
 Arranging contents
 Selecting appropriate training methods
 Selecting appropriate learning aids
 Putting the entire schedule in a time frame
Assessment of training:
This helps the trainers to know how much the trainees have learned. This includes
three components through which the program can be assessed. A theoretical, practical, and
oral approach is commonly used. This can be grouped under formal or informal testing
methods.
Informal testing:
This can be conducted either inside the class or outside. A checklist can be used for
assessing the objectives covered, content and teaching aids used, and participation by
trainees.
Formal testing:
This can be done in three ways viz; by conducting practical tests, oral tests, or written
tests.
 Practical test – this includes demonstration classes. For example; to demonstrate how
to weigh a child accurately for assessing the growth pattern, or weighing the edible
portion of a vegetable,
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 Oral test – in this type of session verbal questioning and answers can be used.
 Written test – this is considered one of the best ways to assess the trainee's knowledge
by writing answers to questions.
Phase-III: Evaluation:
Evaluation is a systematic and scientific process of determining the extent to which an
action or set of actions was successful in the achievement of set objectives in a program.
Evaluation is done to assess whether or not changes have taken place as a result of
implemented activities. The evaluation should be planned based on all phases of program
planning, implementation, and management. The goals and objectives of the program should
be linked to the evaluation process to assess the success of the training program and the
trainer should justify the use of resources or inputs in a particular training program. Feedback
obtained from the receiver can help to assess the degree of success of the training program.
Feedback provides a method of eliminating miscommunication. Feedback is thought to be
most effective in a face-to-face conversation where feedback is instantaneous.
16.4: APPROACHES, TOOLS, AND TECHNIQUES
It is very important to know about nutrition and health education. No nutrition and
health program can indeed be successful without the proper usage of approaches and methods
that effectively reach the beneficiaries. You need to understand certain concepts before
studying different types of approaches in Nutrition and Health education. The concepts that
should know to you are the meaning of health, health education, objectives of health
education, the meaning of nutrition, nutrition education, objectives of nutrition education, the
meaning of approach, and traditional and modern approach. As you read this, you will aware
of different types of approaches used in the community to educate people on nutrition and
health. You will also learn about how these approaches are useful in the framework of
nutrition and health education.
Meaning and Types of approaches:
You have learned about two important arms of community – health and nutrition. As
a nutrition and health educator, you should aware of the different types of approaches
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adopted in health and nutrition education. Before learning about different types of
approaches, it is necessary to understand the meaning of 'approach'.
The term 'approach' refers to the way of dealing with something. In community
education, the term approach refers to the method adopted for studying or knowing the
community. A variety of approaches are in practice in the area of community education.
Approaches to health and nutrition education are grouped into two types – traditional
approaches and modern approaches. Traditional approaches include instructional and folk
approaches like role play, storytelling, folk songs/music, and puppetry. Modern approaches
include the analytical approach, dialogue approach, persuasive approach, educational games,
and simulation.
Traditional Approaches:
Traditional approaches refer to long-established customs found in society that has
traditionally been deemed appropriate. Traditional folk media is a term used to denote
'people's performances'. This term refers to the performing arts which can be described as the
cultural symbols of the people. It is also known as back-to-basics, conventional education, or
customary education. Traditional approaches are often loosely and interchangeably referred
to as traditional media, folk media, and folk art forms such as drama and songs. Folk
approaches are strong and effective means for the development of communication. They are
rooted in indigenous culture. Traditional methods like folk songs, dances, stories, and dramas
are popular means of communication for recreation. These methods have also been used for
moral, religious, and socio-political education. These forms are still energetic and receptive
to new ideas, and therefore have great potential as development communication tools. By
using these traditional methods in nutrition and health education, community people will
receive new messages and get entertainment concurrently.
Traditional media forms are personal, familiar, and credible. They are far less
expensive and much more effective as they communicate at a direct and personal level. Even
community members can easily identify themselves as part of their folk art forms. Therefore,
despite the rapid diffusion of new communication technologies, traditional approaches
continue to demonstrate value as effective vehicles for developmental messages. The appeal
of traditional methods is also that they are universal and intimate. They are popular regardless
of the educational, social, and economic standing of any community. They use colloquial
KSOU, Mysuru. 382

dialects, which makes the communication clear and distinct. Another big advantage of folk
media is that it is flexible in accommodating new ideas, themes, and issues. Folk media
satisfies the inner need for self-expression and everyone can participate in it. Thus, it is
particularly effective for community learning. Folk art forms not only preserve and
disseminate the wisdom, tradition, and culture of the past but they can also be adapted to
incorporate modern development education. Let us study traditional approaches used in
community education in detail.
Instructional approach:
The definition of instructional methods is "an educational approach for turning
knowledge into learning." Instructional methods are the "how to" in the delivery of
training. The terms 'teaching' and 'instruction' are almost synonymously used to refer
to any activity on the part of one person/instructor intended to facilitate learning on
the part of another person/learners.
Folk approaches:
The Folk media in India play a very important role, especially in rural areas,
where the majority of people are less literate and ignorant about scientific facts. Folk
media carry diverse messages of education, political, social, healthcare, and
agricultural innovation to inform and educate rural people. In village life, even though
medium of mass communication like radio and television has entered greatly, folk
media are still alive and expose the people to various messages, related to the facts
that happen in village life every day.
Folk Music and Dance:
India is a land of cultural diversity. Every region in India has its form of folk
music. There are more than 300 folk musical styles in India. These folk musical styles
have been and are used in all languages and states. This rich tradition of folk music is
very much alive in not just rural India, but also some metros. Folk music is very
different from classical music as well. Folk dance is a term broadly used to describe
all forms of folk and tribal dances in regions across India. Folk dance forms are
practiced in groups in rural areas as an expression of their daily work and rituals.
KSOU, Mysuru. 383

Ballad form of folk approach:

The common ballad forms are Burrakatha (Andhra Pradesh), Posada
(Maharashtra), Villupattu (Tamil Nadu), and many others in different parts of the
country. Let us see the main features of these ballad forms.
Street theatre:
During the decade between seventy and eighty, street theatre appeared
vigorously in Indian mass communication. Street theatres which can be seen in
different types and styles involve the activities of different groups or organizations
who accomplish such dramatic play or show openly to render their messages to the
public widely. Especially, political parties, student unions, religious groups, Women's
welfare organizations, and NGOs, are involved in presenting such attractive shows or
plays, to draw public attention as well as generate awareness within them through the
delivered messages.
Puppetry:
Puppetry is one of the ancient forms of performing folk arts. It is the most
popular as well as adored folk medium that can attract children and adults equally.
The word puppet comes from the French 'Poupee’ or the Latin ‘Pupa’, both meaning
`dolls’. In Sanskrit, puppets are termed `Putraka’, `Putrika', or `Puttalika’, all of which
are derived from the root ‘Putta’ equivalent to Putra (son). It is derived from ancient
Indian thoughts that puppets have life.
Modern Approaches:
You have learned about traditional approaches, and now we will know about modern
approaches focusing on characteristics, processes, and uses in community education. Modern
approaches are participatory and emphasize the involvement of learners in the process of
learning. Modern approaches include analytical, dialogue, persuasion, and games. After
studying the modern approach you will be able to understand the difference between
traditional and modern approaches, the major features of the various modern approaches, and
how these approaches could be adopted in nutrition and health education.
The principles governing the modern participatory approaches are
Purpose: Participants must know why they have selected a particular issue.
Activity: Through activity-centered learning, participants think, plan and do things.
KSOU, Mysuru. 384

Reality: The learners are provided with opportunities to exercise their talent in real-
life situations.
Experience: the learner works alone or with a group to carry out the task and gains
valuable experience.
Freedom: Learners are encouraged to act by themselves and they have to decide by
themselves to deal with the situation. Such freedom helps the learner to
unfold and express themselves fully.
Utility: The approach ensures the practical utility of the knowledge gained by the
learner.
The modern approach of participatory learning aims at both information transmission
(Knowledge) and behavior change (Practice). It is very important to have some skills to
facilitate participatory approaches in community education
Analytical approach:
The word analysis means separating a problem into its constituent elements. Doing so
reduces complex issues to their simplest terms. An analytical approach is the use of
an appropriate process to break a problem down into the smaller pieces necessary to solve it.
Each piece becomes a smaller and easier problem to solve. The main objective of the
analytical approach in health and nutrition education is to stimulate analytical thinking
wherein learners are encouraged to analyze a particular situation and react to it. In the
analytical approach, instruction from the facilitator is less and discussion should be initiated
by posing the question. The varied reactions of the group usually provoke discussion which
could be guided by the facilitator to provide a meaningful solution to the problem through a
series of steps.
Nutrition and health issues suitable for an analytical approach
 Food intake and its adequacy for good health
 Nutritional problems in children
 Obesity and lifestyle factors
 Malaria and environmental hygiene
Dialogue approach:
A dialogue approach is a form of constructivism and a popular educational means for
transformative learning. The approach which provides more opportunities for sharing
KSOU, Mysuru. 385

knowledge, skills, and experiences is known as Dialogue. The focus of education shifts from
what the teacher says to what the learner does, from learner passivity to learners as active
participants in the dialogue that leads to learning. A dialogue approach to education views
learners as subjects in their learning and honors central principles such as mutual respect and
open communication. Learners are invited to actively engage with the content being learned
rather than being dependent on the educator/facilitator for learning. Ideas are presented to
learners as open questions to be reflected on and integrated into the learner's context. This
approach intends to result in more meaningful learning that has an impact on behavior.
Persuasive approach:
Persuasion is a process aimed at changing a person's / a group's attitude or behavior
toward some event, idea, object, or another person (s) by using written or spoken words to
convey information, feelings, or reasoning, or a combination thereof. This approach involves
persuasive communication, in which several variables can be recognized, whose interaction
determines the outcome of the communication. The instructor/facilitator, message,
receiver/learner can be controlled to some extent with the management of variables that may
assist in promoting changes in the attitude and behavior of the learners. The key functions of
persuasive communications are stimulation, convincing, a call to action, increased
consideration, and tolerance of alternate perspectives.
Educational games:
Educational games are games explicitly designed for educational purposes, or which
have incidental or secondary educational value. All types of games may be used in an
educational environment. Educational games are games that are designed to teach people
about certain subjects, expand concepts, reinforce development, understand a historical event
or culture, or assist them in learning a skill as they play. Educational games are also called
Game-based learning which includes board, card, and video games puzzles, etc.
Resource-based teaching–learning approach can greatly assist the development of

attitudes and abilities for independent, lifelong learning. Both traditional and modern
approaches are very interesting and innovative for learners, especially in nutrition and health
education. Traditional approaches can be effective when information has to be conveyed to
less literate people in relatively small groups. Modern approaches are practically oriented;
KSOU, Mysuru. 386

involve the learners in the process of thinking and acting. Trainees in the field of health and
nutrition education have to develop the skills of handling folk approaches and actively
participate in modern approaches so that they can bring a lot of change in the attitude and
behaviors of community people.
16.5: NUTRITION EDUCATION/ COUNSELING PROGRAMMES:
The causes of malnutrition are directly related to inadequate dietary intake and disease
but indirectly related to many other factors, including child care and feeding, sanitation, and
hygiene. Counseling should address these various factors to result in sustainable change. This
section presents guidance on the content of nutrition counseling.
In 1997, the USAID-funded Basic Support for Institutionalizing Child Survival
(BASICS) Project developed a "Minimum Package for Nutrition" that was adopted by the
World Health Organization (WHO) and UNICEF in 1999 as "Nutrition Essentials" and later
renamed the Essential Nutrition Actions (ENA). Organized by a lifecycle approach, the ENA
was an affordable and effective intervention to improve the nutritional status of women and
children and a framework for program actions to deliver nutrition services and messages on.
 Exclusive breastfeeding for 6 months
 Adequate complementary feeding starting at 6 months with continued breastfeeding
for 2 years
 Appropriate nutrition care for sick and malnourished children
 Adequate intake of vitamin A for women and children
 Adequate intake of iron for women and children
 Adequate intake of iodine by all household members
Nutritionists develop a set of Critical Nutrition Actions (CNA), originally for people
living with HIV but later applied to adults with any infectious or chronic disease. The CNA
messages (listed next) can be used in nutrition education and individual counseling.
 Get weighed regularly and have weight recorded

 Eat a variety of foods and increase your intake of nutritious foods.
 Drink plenty of boiled or treated water
 Avoid habits that can lead to poor nutrition and poor health
KSOU, Mysuru. 387

 Maintain good hygiene and sanitation.

 Get exercise whenever physically possible.
 Prevent and seek early treatment of infections and manage symptoms through diet
 Take medicines as prescribed and manage side effects and medicine-food interactions
through diet.
Counseling on how to increase energy intake:

 Eat mashed bananas, baked bananas, sweet potatoes, nuts, or porridge
enriched with oil and sugar. Add honey to staple foods.
 Add milk, cheese, or oil to foods.
 Fortify milk by adding 4 spoons (15 ml) of milk powder to 500 ml of milk.
Stir well and keep in a cool place. Use full-fat milk powder if available instead
of skim milk powder. Use this fortified milk in tea, cereals, and in cooking.
 Add yogurt to soups, puddings, cereals, and drinks.
 Stir a beaten egg into porridge or mashed potatoes and cook for a few minutes
more to cook the egg. Do not eat raw eggs.
 Put nut paste, jam, butter/margarine, or tinned fish on the bread.
 Eat nuts as a snack and put chopped nuts on food or add nut paste to food.
 Eat foods rich in fat, such as avocado, fatty fish, coconut, oil, and fried foods,
if tolerated.
 Eat fermented and germinated (sprouted) foods.
Nutrition counseling for pregnancy:
Healthy, well-nourished pregnant women should gain between 10 kg and 14 kg
during pregnancy to increase the likelihood of delivering a full-term infant weighing at least
3.3 kg. Below are the recommended extra energy and protein requirements during pregnancy.
However, the guidelines are based on data from Western countries and have been questioned
for their appropriateness across other populations. Research is needed to further refine the
Recommendations for Gestational Weight Gain.
Counseling on Infant and Young Child Feeding (IYCF):
Inadequate feeding, care, and hygiene practices cause malnutrition in children.
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Breastfeeding: is the most effective preventive public health intervention for child survival
and has the potential to prevent 13 percent of all deaths in children under 5 in the developing
world. The benefits of breastfeeding are listed below.
 Breast milk provides all the food and water an infant needs for the first 6 months of
life.
 Breast milk is completely hygienic and contains antibodies that protect infants from
disease.
 Its composition adjusts to serve the special needs of pre-term infants, newborns, and
older infants.
 Breast milk includes fatty acids absent in formula or animal milk that are important in
brain development.
 Breastfeeding promotes mother-child bonding and psychosocial development.
 A breastfed infant has lower risks of illness and death from diarrheal disease and
pneumonia, reduced incidence of allergies and otitis media (ear infections), and in
later life, reduced incidence of overweight, obesity, and some chronic disease.
 There is evidence that exclusive breastfeeding improves children’s performance on
intelligence tests.
 For mothers, early initiation of breastfeeding helps contract the uterus and expel the
placenta, and reduces postpartum bleeding.
 Exclusive breastfeeding delays the return of menstruation, helping mothers recover
iron stores and acting as a natural form of birth spacing.
 Women who breastfeed have lower rates of premenopausal breast and ovarian
cancers.
Complementary feeding:
Should begin when infants reach the age of 6 months. They should be offered semi-
solid foods and gradually introduced to the regular family diet by the age of about 1 year,
with continued breastfeeding until they are around 2 years or older. Below are counseling
messages on complementary feeding.
 Feed foods from all food groups in each meal, not only starchy foods. Try different
combinations, tastes, and textures if children refuse foods. Young children have small
stomachs so they should eat small, frequent meals. When children are 9 to 24 months
of age, feed three or four main meals (one meal = 1 cup) and two nutritious snacks
KSOU, Mysuru. 389

between meals, in addition to milk. As children get older, increase the number of
foods.
 Feed finely flaked fish, eggs, beans, ground-up nuts, finely sliced meat, or other soft
and easily digestible foods from the family pot.
 Feed mashed fruits and vegetables such as ripe banana, pawpaw, avocado, and
pumpkin as often as possible.
 Add 1–2 teaspoons of oil, butter, margarine, milk, or groundnuts/sesame paste to each
cup of food to increase nutrient and energy intake.
 Feed fermented, germinated, or fortified products.
 For snacks give finger foods (foods children can pick up easily), such as sliced fruit or
bread with butter.
 Give children who are not receiving breast milk or animal foods a vitamin and
mineral supplement.
 Give children boiled or treated water to drink after they eat, even if they are still
breastfeeding.
 Do not feed children sugary drinks such as sodas and processed juices.
 Do not feed spicy foods, which may make children afraid to try other nutritious foods.
 Feed responsively (notice children’s hunger signs, show love and care, talk to the
children, and make eye contact).
 Feed slowly and patiently, encouraging but not forcing children to eat.
 Avoid distractions during meals so children don’t lose interest in eating.
Counseling on water, sanitation, and hygiene (WASH):

Poor water, sanitation, and hygiene conditions are associated with disease and
disability all over the world. Diarrheal diseases are the most common illnesses resulting from
contaminated drinking water and food. Diarrhea is most often caused by gastrointestinal
infections that kill around 2.2 million people each year, mainly children in developing
countries. WHO estimates that contaminated food causes 230,000 deaths every year and that
unsafe food causes more than 200 diseases ranging from diarrhea to cancer. Frequent diarrhea
contributes to child stunting and is the second highest cause of illness and death in children
under 5.15 almost all diarrheal illnesses in developing countries can be attributed to unsafe
water and inadequate sanitation and hygiene. Poor WASH practices may be responsible for
KSOU, Mysuru. 390

up to one-half of underweight women and children. Children, pregnant women, the elderly,
and people with compromised immune systems are especially vulnerable to food- and water-
borne bacteria, viruses, and parasites. It is thought that poor hand washing, poor food hygiene
and sanitation, and lack of clean drinking water contribute to child stunting by inducing a gut
disorder called environmental enteric dysfunction. Constant exposure to fecal matter ingested
by mouth results in the flattening of the villi (finger-like projections that protrude from the
lining of the intestine). This limits the body's ability to absorb nutrients and increases
exposure to microbes that lead to intestinal inflammation. These changes divert energy from
growth to fight asymptomatic infection.
16.6: SUMMARY:
 In this unit, we learned the concept of nutrition education. This was mainly started as
an intervention program to educate the community about the extent, magnitude, and
prevalence of various nutrition problems and their consequences.
 Planning nutrition education is very important. The program has to be planned based
on the target audience.
 The selection of educational media is very important because it plays a major role in
the transmission of a message to the targeted population.
 The implementation of nutrition education involves the production of support
materials that are used for educating the community and imparting training for the
resource person.
 Training is a very major aspect through which the message can be effectively
communicated. Deciding on appropriate learning aid and framing a schedule for
achieving success are the other important aspects involved in the implementation
phase.
 Evaluation is the last phase of the nutrition education program. Evaluation can be
conducted at any phase.
 During the evaluation, the communicator would observe whether the change has taken
place or not. With all these basic steps an effective nutrition education can be planned
for educating the community.
KSOU, Mysuru. 391

 It is very important to know about nutrition and health education. No nutrition and
health program can indeed be successful without the proper usage of approaches and
methods that effectively reach the beneficiaries.
 Nutrition education is not merely a process of transferring facts or information about
the nutritive value of foods, the role of food in preventing nutrient deficiency
disorders, or methods of food production, marketing, distribution, and preparation.
 Nutrition counseling is a two-way interaction through which a client and a trained
counselor interpret the results of a nutrition assessment, identify individual nutrition
needs and goals, discuss ways to meet those goals, and agree on the next steps.
 Planning means giving shape and structure to the different elements involved in the
process of nutrition education.
 It is very important to know about nutrition and health education. No nutrition and
health program can indeed be successful without the proper usage of approaches and
methods that effectively reach the beneficiaries.
 The term 'approach' refers to the way of dealing with something. In community
education, the term approach refers to the method adopted for studying or knowing
the community.
 The causes of malnutrition are directly related to inadequate dietary intake and disease
but indirectly related to many other factors, including child care and feeding,
sanitation, and hygiene. Counseling should address these various factors to result in
sustainable change.
 Complementary feeding should begin when infants reach the age of 6 months. They
should be offered semi-solid foods and gradually introduced to the regular family diet
by the age of about 1 year, with continued breastfeeding until they are around 2 years
or older.
16.7: GLOSSARY
Optimal counseling: contributes to successful health and nutrition outcomes.
Ethics: is based on well-founded standards of right and wrong that prescribe what humans
ought to do, usually in terms of rights, obligations, benefits to society, fairness, or
specific virtues.
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Approach: it is referred to the way of dealing with something.
UNICEF: United Nations International Children's Emergency Fund.
Essential nutrition action (ENA): It is an approach to expand the coverage of seven

affordable and evidence-based nutrition actions to improve the nutritional status of
women and children.
Complementary feeding: Around the age of 6 months, an infant's need for energy and
nutrients starts to exceed what is provided by breast milk, and complementary foods
are necessary to meet those needs.
Ballad forms of folk – narrative music/dancing songs.
16.8: CHECK YOUR PROGRESS -I
15. Define nutrition education.

16. Name the goals and objectives of nutrition education.
17. What is nutrition counseling?
18. List the ethical principles of counseling.
19. Write the importance of nutrition education.
16.9: CHECK YOUR PROGRESS -II

20. Discuss the importance of nutrition education. And add a note on the process of
planning nutrition education.
21. Name the steps involved in counseling.
22. What are the phases in planning nutrition education
23. Mention the approaches, tools, and techniques of nutrition education.
24. Define complementary feeding.
25. Describe the planning and evaluation process of nutrition education.
16.10: REFERENCES:
1. Adapted from Corey, G. and Callanan, P. 2011. Issues and Ethics in the Helping
Professions. 8th edition. Fullerton, CA: California State University; Welfel, E.R.
2010. Ethics in Counseling and Psychotherapy: Standards, Research, and Emerging
Issues. 4th edition. Pacific Grove, CA: Brooks/Cole.
KSOU, Mysuru. 393

2. Bhutta, Z.A., et al. 2013. “Evidence-Based Interventions for Improvement of

Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet.
Vol. 382, pp. 452–77.
3. FAO. 2001. Human Energy Requirements. Report of a Joint FAO/WHO/UNU Expert
Consultation. Rome, 17–24 October. Food and Nutrition Technical Report Series.
4. WHO. 2007. Protein and Amino Acid Requirements in Human Nutrition. Report of a
Joint WHO/FAO/UNU Expert Consultation. WHO Technical Report Series 935.
5. Pruss-Üstün, A.; Bos, R.; Gore, F.; and Bartram, J. 2008. Safer Water, Better Health:
Costs, Benefits, and Sustainability of Intervention to Protect and Promote Health.
Geneva: WHO.
6. Ngure, F.M. et al. 2014. “Water, Sanitation, and Hygiene (WASH), Environmental
Enteropathy, Nutrition, and Early Child Development: Making the Links.” Annals of
the New York Academy of Sciences. Vol. 1308, pp. 118–28.
16. 11: REFERENCES TO FURTHER
1. Bentley Robert J. and Brookins-Fisher Jodi, (2001) Community Health Education

Methods – A Practioner’s Guide. Boston: Jones and Bartlett Publishers.
2. Chalkley, A.M. (1987) A Textbook for the Health worker volume 1New Age
International Publishers
3. Contento Isobel R. (2007) Nutrition Education – Linking, Research, Theory, and
Practice. Boston: Jones and Bartlett Publishers.
4. Govt of India (1961) Extension education in community development, New Delhi: The
Directorate of Extension, Ministry of Food and Agriculture, Govt of India.
5. Mishra R.C. (2009) Health and Nutrition Education, New Delhi: A P H Publishing
House.
6. Rayudu C.S. (1998) Media and Communication Management, Revised and Enlarged
Edition, Mumbai: Himalaya publishing house.
KSOU, Mysuru. 394

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KARNATAKA STATE OPEN UNIVERSITY

Mukthagangothri, Mysuru – 570 006

M.Sc. in Food and Nutrition Sciences

MFNSDSC-2.2: Community Nutrition

MFNS DSC 2.2: COMMUNITY NUTRITION

(Blocks -I, II, III and IV)

Prof. Neena Joshi MFNSDSC 2.2 Block II 5, 6,7, 8, 9, 10,11, 12

PROOF READING AND EDITORIAL

Dr. Anitha C. Member

Dr. Vanitha Reddy Member

Unit-1 Concept of Community 03

Unit-5 Macro nutrient deficiency and excess 89

BLOCK-I: CONCEPT AND SCOPE OF COMMUNITY NUTRITION

After studying the Block on you will be able to;

UNIT –I: CONCEPT OF COMMUNITY

STRUCTURE OF THE UNIT:

1.2: CONCEPT OF COMMUNITY

1.4: HEALTH STATISTICS

1.5: MORTALITY RATE

1.6: MORBIDITY RATE

1.7: NUTRITIONAL ASSESSMENTS

1.8: NUTRITION SCREENING

1.9: NUTRITION MONITOR

1.14: CHECK YOUR PROGRESS-1

1.15: 14 CHECK YOUR PROGRESS-2

1.18: REFERENCES FOR FURTHER READING

A community is a specific group of people who share common characteristics, e.g. a

Community nutrition is the science related to the practical application of nutritional

Community nutrition is the study of assessing food and nutrition situations in

1.2: CONCEPT OF COMMUNITY NUTRITION:

The World Health Organization (WHO) deﬁnes a community as a social group

 Primary prevention involves designing activities to prevent a disease or condition

These professionals intercommunicate with other professionals for a wide range of

Figure-1: Quantitative Study of Human Populations

• Age of mother at first birth: It makes a big difference if a woman is a 22-year-old

1.4: HEALTH STATISTICS

Health statistics are numbers that summarize information related to health.

About Health Statistics Modules:

1.5: MORTALITY RATE

Mortality is defined as the demographic event of death. Since death is a biological

1.5.1: Measures of Mortality

Specific Death Rate:

as neonatal mortality. The equation to calculate neonatal mortality is as follows:

Post-neo-natal Mortality rate:

The equation is as follows:

Perinatal Mortality rate:

Perinatal mortality rate

Infant Mortality rate:

Maternal Mortality rate:

1.6: MORBIDITY RATE

 Morbidity rates can be used to determine the overall health of a population.

1.7: NUTRITIONAL ASSESSMENT

Nutritional status is the condition of health of the individual as influenced by the

utilization of the nutrients. It can be determined by the correlation of information obtained

A nutritional assessment is an in-depth evaluation of both objective and subjective

Nutritional assessment aids in identifying:

1.7.1: NUTRITIONAL ASSESSMENT TECHNIQUES

The nutritional status can be assessed by the following methods:

b) Assessment of socio-economic status and