Nutrition and health; Medicine and social sciences

Q. Describe the role of micronutrients in human health. Briefly write the

methods of assessment of nutritional status.
Q. Write the steps of nutritional assessment (diet survey) of family allotted
to you.
Ans. - Nutrients are organic and inorganic complexes contained in food. These
may be divided into :

(i) Macronutrients : These are proteins, fats and carbohydrates which

are often called "proximate principles" because they form the main
bulk of food.

(ii) Micronutrlents : These are vitamins and minerals. They are called
micronutrients because they are required in small amounts which may
vary from a fraction of a milligram to several grams.

VITAMINS

Vitamins are a class of organic compounds categorized as essential

nutrients. They are required by the body in very small amounts.

Vitamins do not yield energy but enable the body to use other
nutrients. Since the body is generally unable to synthesize them in
sufficient amounts they must be provided by food. A well balanced diet
supplies in most instances the vitamin needs of a healthy person.

Vitamins are divided into two groups :

(a) fat soluble vitamins, viz., vitamins A, D, E and K; and
(b) water soluble vitamins, viz., vitamins of the B-group and vitamin C.

Each vitamin has a specific function to perform and deficiency of any

particular vitamin may lead to specific deficiency diseases.
MINERALS

More than 50 chemical elements are found in the human body, which
are required for growth, repair and regulation of vital body functions.

These can be divided into three major groups :

(a) MAJOR MINERALS : These include calcium, phosphorus, sodium,
potassium and magnesium
(b) TRACE ELEMENTS: These are elements required by the body in
quantities of less than a few milligrams per day, e.g. iron, iodine,
fluorine, zinc, copper cobalt, chromium, manganese, molybdenum,
selenium, nickel, tin, silicon and vanadium
(c) TRACE CONTAMINANTS WITH NO KNOWN FUNCTION : These
include lead, mercury, barium, boron. and aluminium.

Only a few mineral elements (e.g., calcium, phosphorus, potassium,

sodium, iron, fluorine, iodine) are associated with clearly recognizable
clinical situations in man.

The bio-availability of minerals such as iron and zinc may be low in a

total vegetarian diet because of the presence of substances such as
phytic acid. Besides, large amounts of dietary fibre may interfere with
proper absorption. Man is not likely to suffer from trace element
deficiencies as long as he is omnivorous.

Surveys have shown that mineral deficiencies are no greater among

vegetarians than among non-vegetarians. In fact, man's need for trace
elements has not yet been precisely determined.

Trace elements should not be used as dietary supplements, since

excessive amounts can have injurious effects.
ASSESSMENT OF NUTRITIONAL STATUS

The main objective of a "comprehensive" nutritional survey is to obtain

precise information on the prevalence and geographic distribution of
nutritional problems of a given community, and identification of
individuals or population groups "at risk" or in greatest need of
assistance. The purpose of nutritional assessment is to develop a health
care programme that meets the needs defined by that assessment.

The assessment methods include the following :

1. Clinical examination : It is the simplest and the most practical

method of ascertaining the nutritional status of a group of individuals.
When two or more clinical signs characteristic of a deficiency disease
are present simultaneously, their diagnostic significance is greatly
enhanced.

2. Anthropometry : Anthropometric measurements such as height,

weight, skinfold thickness and arm circumference are valuable
indicators of nutritional status.

3. Laboratory and biochemical assessment :

(a) LABORATORY TESTS: (i) Haemoglobin estimation
(ii) Stools and urine
(b) BIOCHEMICAL TESTS : reveal only current nutritional status;
they are useful to quantify mild deficiencies.

4. Functional indicators : Functional indices of nutritional status are

emerging as an important class of diagnostic tools.
For example, functional indicator of Structural integrity
a. Erythrocyte fragility — Vit. E, Se
b. Capillary fragility — Vit. C
c. Tensile strength — Cu
5. Assessment of dietary intake : The value of nutritional assessment
is greatly enhanced when it is supplemented by an assessment of
food consumption. A diet survey may be carried out by one of the
following methods :

(i) WEIGHMENT OF RAW FOODS : This is the method widely

employed in India as it is practicable and if properly carried out is
considered fairly accurate. The survey team visits the households,
and weighs all food that is going to be cooked and eaten as well as
that which is wasted or discarded. This duration of the survey may
vary from 1 to 21 days, but commonly 7 days which is called ''one
dietary cycle".

(ii) WEIGHMENT OF COOKED FOODS : Foods should preferably be

analyzed in the state in which they are normally consumed, but this
method is not easily acceptable among people.

(iii) ORAL QUESTIONNAIRE METHOD : This is useful in carrying out

a diet survey of a large number of people in a short time. Inquiries
are made retrospectively about the nature and quantity of foods
eaten during the previous 24 or 48 hours. If properly carried out,
oral questionnaire method can give reliable results. A diet survey
may also include collection of data relating to dietary habits and
practices.

The data that is collected have to be translated into

(a) mean intake (grams) of food in terms of cereals, pulses,
vegetables, fruits, milk, meat, fish ancl eggs. and
(b) the mean intake of nutrients per adult man value or "consumption
unit''.

This exercise requires the use of suitable tables of food composition.

e.g., ICMR publication : "Nutritive Value of Indian Foods"
 6. Vital statistics : An analysis of vital statistics - mortality and
morbidity data - will identify groups at high risk and indicate the
extent of risk to the community. Mortality in the age group 1 to 4
years is particularly related to malnutrition.

7. Assessment of ecological factors : In any nutrition survey it is

necessary to collect ecological information of the given community in
order to make the nutrition assessment complete. A study of the
ecological factors comprise the following :
(a) FOOD BALANCE SHEET
(b) SOCIO-ECONOMIC FACTORS
(c) HEALTH AND EDUCATIONAL SERVICES
(d) CONDITIONING INFLUENCES

The different methods used for the appraisal of nutritional status

are not mutually exclusive; on the contrary, they are complimentary.

Q. Define survey and its objective. Enumerate different methods of diet

survey (Assessment Methods) and methods you have adopted to assess
nutritional status in family study programme.
Ans. - Diet survey is defined as “The scientific assessment of food
consumption and using this data for various purposes, including
assessment of nutritional status.”

Objectives of dietary assessment

1. To improve the diet of people at household level particularly to
improve diets or feeding of young children, pregnant and lactating
women.
2. For planning of national food strategies especially in food crisis.
3. As a research purpose to assess the effect of nutrition education
program.
4. Periodic dietary surveys done at time intervals provide information
on trends of food consumption.
5. To know the specific preference for a food and foods avoided/
disliked and alternate foods consumed during special conditions like
droughts and in tribal areas.
6. To provide evidence-based data for designing programmes on
nutrition.

Methods of diet survey

1. Food balance sheet method
2. Inventory method
3. Weighment method
4. 24 hour recall method
5. Dietary score method
6. Food frequency questionnaire
7. Duplicate sample/chemical analysis method
8. Expenditure pattern method
9. Diet history
10. Recording method

24 HOURS RECALL METHOD

It needs a trained interviewer to ask the respondent to remember in

detail all the food and drink they consumed during the period of time
in the recent past (often previous 24 hours).

1. Enlist all the family members who partook the meals yesterday.
2. There completed age (in years for adults in months for infants and
young children.)
3. Their physiological status (pregnancy, lactation)
4. Economic status
5. This helps to arrive adult consumption units
6. Housewife/individual is asked which food and what amounts were
consumed on previous day or yesterday.
7. Avoid 3F’s - Festival, Fast, Feast.
8. An account of raw ingredients used for each of the preparations is
obtained.
9. Information on total cooked amount of each preparation is noted in
terms of standardised cups.
10. An extended and more accurate version of this method is the
multiple pass 24 hour recall. The diet is assessed over a period of 3
to 5 days during which the respondent is asked to recall and
describe all food and drinks consumed in the 24 hour prior to the
interview.
11. Information is recorded and analysed in computed by an expert.

Advantages
1. Low respondent burden
2. Easy in administration
3. Minimisation of biases associated with altering food intake because
of knowledge that one is being observed.
4. Can be administered by telephone

Limitations
1. Forgetting
2. Deliberate misreporting
3. Need for a trained observer to administer
4. Costs associated with computerised analysis of records
5. Need for several days of Intex to obtain estimate of usual diet.
Q. Kuppuswamy’s Socioeconomic Status Scale.
Ans. - Socioeconomic status (SES) is one among important indicators to
evaluate the health status and nutritional status of a family. It is a
position attained by any individual within a system of hierarchical social
structure.

Kuppuswamy scale is the most widely used scale for determining the
socio-economic status of an individual or a family in urban areas.

Updated for the year 2020

 The scale was initially developed by Kuppuswamy in the year 1976
including index parameters like education, occupation, and total income
which was further modified in later years to include head of families
educational status, occupational status and overall aggregate income of
the whole family, pooled from all sources.

The Kuppuswamy SES has included 3 parameters and each parameter

is further classified into subgroups and scores have been allotted to
each subgroup as mentioned in the table above.

The total score of Kuppuswamy SES ranges from 3-29 and it classifies
families into 5 groups, “upper class, upper middle class, lower middle
class, upper lower and lower socio-economic class.”

Q. Consumer protection act.

Ans. - The Consumer Protection Act 1986 provided consumers a forum for
speedy redressal of their grievances against medical services.

Under the general law, a member of a profession is required to show a

standard of catre which a person of that profession is expected to
posses.

According to this Act, the decision should be taken within 3 to 6

months. There is no court fee payment and the person can plead his
own case. COPRA is a piece of comprehensive legislation and recognizes
six rights of the consumer, namely :
1. right to safety;
2. right to be informed;
3. right to choose;
4. right to be heard;
5. right to seek redressal; and
6. right to consumer education.
 If a patient or the relations of a patient feel that the suffering or
death of a patient is because of either negligence by the concerned
doctor or the heatlh facility, they can complain to the Medical Council
of India or to the Consumer Court.

The Medical Council of India, which is a statutory body created to

monitor the medical profession has only ethical jurisdiction. The council
can only cancel the registration of the concerned doctor temporarily or
permanently but cannot punish a doctor or give a compensation.

A complaint against the medical professional can be filed in the

consumer court. It should contain all the details of the case, an expert
certificate or opinion from the doctor of concerned speciality (stating
the complaint is prima facie true and needs further investigation) and
the compensation demanded. These courts can only give compensation.

Q. Technique of interview.
Ans. - Conducting an interview is both an art and science. Sociologists have
described the following steps for conducting an interview

1. ESTABLISHING CONTACT The first requisite before conducting an

interview is to establish contact with the interviewee. Prior
appointment regarding the time and place of interview is always
desirable.

2. STARTING AN INTERVIEW The beginning should always be made

from a general discussion of the problem. The researcher should let
the interviewee do most of the talking, while he should himself listen
to it attentively guiding and directing the interviewee about the
subject matter wherever necessary. All controversial matters must be
carefully avoided.
3. SECURING RAPPORT In the beginning every interviewee proceeds
very cautiously giving only formal information. It therefore requires
tact on the part of the researcher to create a friendly atmosphere
and gain the confidence of the interviewee. Once rapport is gained and
hesitation and shyness are overcome, the research worker must utilize
this situation to the fullest advantage, and use it as best as he can.

4. RECALL At times, the interviewee may be so full of emotion that he

drifts away from the main subject. The researcher should give enough
time to the interviewee to recollect and start again.

5. PROBE QUESTIONS When the interviewee, during an interview

knowingly or unknowinglly side-tracks some important aspect of the
problem, the researcher has to be very cautious in catching these slips.
Great care should be taken in putting probe questions.

6. ENCOURAGEMENT During the course of an interview, it is necessary

to encourage the interviewee from time to time, by interpolating
complimentary expressions.

7. GUIDING THE INTERVIEW Sometimes the interviewee digresses in

his narration to less important topics. It is the duty of the researcher
to guide the subject in the right path without offending him.

8. RECORDING Recording the statements should be reduced to a

minimum during the course of an interview.

9. CLOSING THE INTERVIEW The researcher should bring the

interview to a natural close, followed by the usual forms of greetings.

10. REPORT Soon after the interview, the report should be compiled
when the mind is still fresh about the narration.
Q. Pasteurisation of milk.
Ans. - Pasteurization may be defined as the heating of milk to such
temperatures and for such periods of time as are required to dlestroy
any pathogens that may be present while causing minimal changes in
the composition, flavour and nutritive value (WHO, 1970).

There are several methods of pasteurization. Three are widely used :

(1) Holder (Vat) method : In this process, milk is kept at 63-66 deg C
for at least 30 minutes, and then quickly cooled to 5 deg C. Vat method
is recommended for small and rural communities. In larger cities, it is
going out of use.

(2) HTST method : Also known as "High Temperature and Short Time
Method". Milk is rapidly heated to a temperature of nearly 72 deg C,
is held at that temperature for not less than 15 seconds, and is then
rapidly cooled to 4 deg C. This is now the most widely used method.
Very large quantities of milk per hour can be pasteurized by this
method.

(3) UHT Method : Also known as "ultra-high temperature method." Milk

is rapidly heated usually in 2 stages (the second stage usually being
under pressure) to 125 deg C for a few seconds only. It is then rapidly
cooled and bottled as quickly as possible.

Pasteurization is a preventive measure of public health importance.

Pasteurization kills nearly 90 per cent of the bacteria in milk including
the more heat-resistant tubercle bacillus and the Q fever organisms.
But it will not kill thermoduric bacteria nor the bacterial spores. In
order to check the growth of microorganisms, pasteurized milk is
rapidly cooled to 4 deg C. It should be kept cold until it reaches the
consumer. Hygienically produced pasteurized milk has a keeping quality
of not more than 8 to 12 hours at 18 deg C.
Q. Reference protein and nutritive value of egg.
Ans. -

Q. Vitamin A prophylaxis.
Ans. - Prevention and/or control takes two forms
(a) improvement of people's diet so as to ensure a regular and
adequate intake of foods rich in vitamin A, and

(b) reducing the frequency and severity of contributory factors, e.g.,

PEM, respiratory tract infections, diarrhoea and measles.

Both are long term measures involving intensive nutrition education of

the public and community participation.

Since vitamin A can be stored in the body for 6 to 9 months and

liberated slowly, a short term, simple technology had been evolved by
the National Institute of Nutrition at Hyderabad (India) for community
based intervention against nutritional blindness.

The strategy is to administer 1 lakh IU of vitamin A under national

immunisation programme at 9 months of age. After that, at every
consecutive 6 months a single massive dose of 2 lakh IU of vitamin A in
oil (retinol palmitate) orally is given to preschool children till five years
of age. Total 17 lac IU overall. In this way, the child would be, as it
were "immunized" against xerophthalmia.
Q. Epidemic dropsy (Endemic dropsy).
Ans. - From time to time, outbreaks of "epidemic dropsy" are reported in
India. The cause was not known until 1926, when Sarkar ascribed it to
the contamination of mustard oil with argemone oil.

This toxic substance interferes with the oxidation of pyruvic acid

which accumulates in the blood. The symptoms of epidemic dropsy
consist of sudden, non-inflammatory, bilateral swelling of legs, often
associated with diarrhoea. Dyspnea, cardiac failure and death may
follow. Some patients may develop glaucoma.

The disease may occur at all ages except breast-fed infants. The
mortality varies from 5-50 per cent.

Seeds of Argemone mexicana (prickly poppy) closely resemble mustard

seeds. Argemone oil is orange in colour with an acrid odour. The
following tests may be applied for the detection of argemone oil :
(1) Nitric acid test
(2) Paper chromatography test

The contamination of mustard or other oils with argemone oil may be

accidental or deliberate.

Crops of mustard are gathered during March, and during this period,
the seeds of argemone also mature and are likely to be harvested
along with mustard seeds. Sometimes unscrupulous dealers mix
argemone oil with mustard or other oils.

The accidental contamination of mustard seeds can be prevented at the

source by removing the argemone weeds growing among oil-seed
crops. Unscrupulous dealers may be dealt with by the strict
enforcement of the Prevention of Food Adulteration Act.
Q. Neurolathyrism / Lathyrism.
Ans. - Lathyrism is a paralyzing disease of humans and animals. In the
humans it is referred to as neurolathyrism because it affects the:
nervous system. Neurolathyrism is a crippling disease of the nervous
system characterised by gradually developing spastic paralysis of lower
limbs, occurring mostly in adults consuming the pulse Lathyrus sativus
in large quantities.

Q. Marasmus.
Ans. - Kwashiorkor and marasmus are the two different forms of protein and
energy malnutrition. The main cause of this form of malnutrition is
inadequate protein intake and low concentration of essential amino
acids.
 Kwashiorkor is a severe form of undernutrition, which develops in
individuals on diets with a low protein/energy ratio. The main symptoms
of Kwashiorkor are oedema, wasting, liver enlargement,
hypoalbuminaemia, steatosis and the possible depigmentation of skin
and hair.

Marasmus is the other form of malnutrition, which is caused by

inadequate intake of both protein and energy. It is a form of severe
cachexia with weight loss as a result of wasting in infancy and
childhood. The main symptoms of marasmus are severe wasting, with
little or no oedema, minimal subcutaneous fat, severe muscle wasting
and non-normal serum albumin levels.

Q. Discuss vitamin A deficiency with respect to causes, manifestations and

prevention. How would you assess vitamin A deficiency?
Ans. - The signs of vitamin A deficiency are predominantly ocular. The term
"xerophthalmia" (dry eye) comprises all the ocular manifestations of
vitamin A deficiency ranging from nightblindness to keratomalacia,
Given below is a short description of the ocular manifestations.

(a) Night blindness : Lack of vitamin A, first causes nightblindness or

inability to see in dim light. Nightblindness is due to impairment in
dark adaptation. Unless vitamin A intake is increased, the condition
may get worse.

(b) Conjunctival xerosis : This is the first clinical sign of vitamin A

deficiency. The conjuctiva becomes dry and non-wettable. Instead of
looking smooth and shiny, it appears muddy and wrinkled.

(c) Bitot's spots : Bitot's spots are triangular, pearly-white or

yellowish, foamy spots on the bulbar conjunctiva on either side of the
cornea. They are frequently bilateral.
(d) Corneal xerosis : This stage is particularly serious. The cornea
appears dull, dry and non-wettable and eventually opaque. It does not
have a moist appearance. In more severe deficiency there may be
corneal ulceration. The ulcer may heal leaving a corneal scar which can
affect vision.

(e) Keratomalacia : Keratomalacia or liquefaction of the cornea is a

grave medical emergency. The cornea may become soft and may burst
open. The process is a rapid one.

EXTRA-OCULAR MANIFESTATIONS These comprise follicular

hyperkeratosis, anorexia and growth retardation.

Prevention Already discussed

Assessment of vitamin A deficiency

The formulation of an effective intervention programme for prevention

of vitamin A deficiency (VAD) begins with the characterization of the
problem. This is done by population surveys employing both clinical and
biochemical criteria. These surveys (prevalence surveys) are done on
preschool children (6 months to 6 years) who are at special risk. The
criteria recommended by WHO are as given in Table. The presence of
any one of the criteria should be considered as evidence of a
xerophthalmia problem in the community.
Q. Discuss nutritional profiles of cereals.
Ans. - Cereals are the main sources of energy (carbohydrates). They also
contribute significant quantities of proteins (6 to 12 per cent), minerals
and B-group vitamins. The yellow variety of maize contains significant
amounts of carotene.

ln terms of energy, cereals provide about 350 kcal per 100 graims.
Considering the large amounts in which they are consumed, cereals
contribute 70 to 80 per cent of the total eniergy intake, and more
than 50 per cent of protein intake in typical Indian diets.

Cereal proteins are poor in nutritive quality, being deficient in the

essential amino acid, lysine. The proteins of maize are still poorer,
being deficient in lysine and tryptophan. However, if cereals are eaten
with pulses, as is common in the traditional Indian diets, cereal and
pulse proteins complement each other and provide a more balanced
and "complete" protein intake.

Table below gives the nutritive value of some common cereals.

Q. Define RDA (Recommended Dietary Allowance). What are the attributes of
balanced diet? Describe the basis for proposing a balanced diet for pregnant
& lactating woman.
Q. Prudent diet (Dietary goals).
Ans. - RDA is defined as “The average daily dietary nutrient intake level
sufficient to meet the nutrient requirement of nearly all (97-98 per
cent) healthy individuals in a particular life stage and gender group.”

Balanced diet
A balanced diet is defined as one which contains a variety of foods in
such quantities and proportions that the need for energy, amino acids,
vitamins, minerals, fats, carbohydrate and other nutrients is adequately
met for maintaining health, vitality and general well-being and also
makes a small provision for extra nutrients to withstand short duration
of leanness.

In constructing balanced diet. the following principles should be borne

in mind :
(a) First and foremost, the daily requirement of protein should be met.
This amounts to 10-15 per cent of the daily energy intake.
(b) Next comes the fat requirement, which should be limited to 15-30
per cent of the daily energy intake.
(c) Carbohydrates rich in natural fibre should constitute the remaining
food energy. The requirements of micronutrients (Table 29 and 30)
should be met.

Dietary goals
The dietary goals ("prudent diet") recommended by WHO are as below:

(a) dietary fat should be limited to approximately 15-30 per cent of

total daily intake;
(b) saturated fats should contribute no more than 10 per cent of the
total energy intake; unsaturated vegetable oils should be
substituted for the remaining fat requirement;
(c) excessive consumption of refined carbohydrate should be avoided;
some amount of carbohydrate rich in natural fibre should be taken;
(d) sources rich in energy such as fats and alcohol should be
restricted;
(e) salt intake should be reduced to an average of not more than 5 gm
per day; (in India it averages 15 gm per day);
(f) protein should account for approximately 10-15 per cent of the
daily intake; and
(g) junk foods such as colas, ketchups and other foods that supply
empty calories should be reduced.

There may be conditions under which the above recommendations for

daily food intake do not apply. For example, diet should be adapted to
the special needs of growth, pregnancy, lactation, physical activity, and
medical disorders
Q. What are the major nutritional problems among pregnant mother and
children in our country? Mention the National nutrition programmes.
Ans. - There are many nutritional problems which affect pregnant mothers
and children. The major ones are :

1. Low birth weight

Low birth weight (i.e., birth weight less than 2500gm) is a major
public health problem in many developing countries.

According to Rapid Survey Report on Children 2014, about 18.6 per

cent of babies born in India are LBW as compared to 4 per cent in
some developed countries.

In countries where the proportion of LBW is high, the majority are

suffering from foetal growth retardation. In countries where the
proportion of LBW infants is low, most of them are preterm.

Although we do not know all the causes of LBW, maternal malnutrition

and anaemia appear to be significant risk factors in its occurrence.

Among the other causes of LBW are hard physical labour during
pregnancy, and illnesses especially infections. Short maternal stature,
very young age, high parity, smoking, close birth intervals are all
associated factors.

2. Under nutrition

Undernutrition is identified as a major health and nutrition problem in

India. It is not only an important cause of childhood morbidity and
mortality, but leads also to permanent impairment of physical and
possibly, of mental growth of those who survive.
The nutrition problem frequently encountered, particularly among the
rural poor and urban slums in India are protein-energy malnutrition
and micronutrient deficiencies. The term undernutrition encompasses
stunting (chronic malnutrition), wasting (acute malnutrition) and
underweight.

Children are more vulnerable to the effects of undernutrition.

According to Rapid Survey on Children (RSoC) 2014, about :
- 18.5 % of children are born with low birth weight,
- 29.4 % are underweight (weight for age < 5 years of age),
- 38. 7 % are stunted (height for age <5 years),
- 15.1 % are wasted (weight for hight) and
- < 1 % children under 5 years are having kwashiorkor/Marasmus.

Measurement of Undernutrition
The three commonly used anthropometric indices are :
1. Weight-for-Age (WFA).
2. Length-for-Age or Height-For-Age (HFA).
3. Weight-for-Length or Weight-for-Height (WFH).

3. Xerophthalmia

Xerophthalmia (dry eye) refers to all the ocular manifestations of

vitamin A deficiency in man.

It is the most widespread and serious nutritional disorder leading to

blindness particularly in South-East Asia.

Xerophthalmia is most common in children aged 1-3 years, and is often

related to weaning.

The younger the child, the more severe the disease. Mortality is often
high in this age group.
It is often associated with PEM. The victims belong to the poorest
families.

Associated risk factors include ignorance, faulty feeding practices and

infections particularly diarrhoea and measles which often precipitate
xerophthalmia.

In some countries, "epidemics" of xerophthalmia have occurred in

association with food donation programmes involving skimmed milk,
which is totally devoid of vitamin A.

The States badly affected are the southern and eastern States of
India, notably these are predominantly rice-eating States and rice is
devoid of carotene.

The North Indian States have relatively few cases of xerophthalmia.

4. Nutritional anaemia

Nutritional anaemia is a disease syndrome caused by malnutrition in its

widest sense.

It has been defined by WHO as "a condition in which the haemoglobin

content of blood is lower than normal as a result of a deficiency of
one or more essential nutrients, regardless of the cause of such
deficiency''.

Anaemia is established if the haemoglobin is below the cut-off points

recommended by WHO. By far the most frequent cause of nutritional
anaemia is iron deficiency, and less frequently folate or vitamin B12.
Nutritional anaemia is a worldwide problem with the highest
prevalence in developing countries. It is found especially among women
of child-bearing age, young children and during pregnancy and
lactation.

It is estimated to affect nearly two-thirds of pregnant and one-half

of non-pregnant women in developing countries

In India, Iron deficiency anaemia is the most widespread micronutrient

deficiency affecting all age groups irrespective of gender, cast, creed
and religion, especially among among women belonging to reproductive
age group (15-49 years), children (6-35 months) and low socio-
economic strata of the population.

Overall, 72. 7 per cent of children up to the age 3 years in urban

areas and 81.2 per cent in rural areas are anaemic.

NATIONAL NUTRITION PROGRAMMES

The Government of India have initiated several large-scale

supplementary feeding programmes, and programmes aimed at
overcoming specific deficiency diseases through various Ministries to
combat malnutrition. They are as shown in table given below
Q. Protein Energy Malnutrition.
Q. Enumerate different levels of prevention with their suitable modes of
Intervention. Describe how will you apply these level of prevention in
prevention of PEM (Protein Energy Malnutrition) in community?
Ans. - The nutrition problem frequently encountered, particularly among the
rural poor and urban slums in India are protein-energy malnutrition
and micronutrient deficiencies.

The term protein energy malnutrition applies to a group of related

disorders that include marasmus, kwashiorkor and intermediate states
of marasmus and kwashiorkor.

PEM is primarily due to

(a) an inadequate intake of food (food gap) both in quantity and
quality, and
(b) infections, notably diarrhoea, respiratory infections, measles and
intestinal worms which increase requirements for calories, protein
and other nutrients, while decreasing their absorption and
utilization.

It is a vicious circle - infection contributing to malnutrition and

malnutrition contributing to infection, both acting synergistically.

Types of PEM : Kwashiorkor and marasmus are the two different

forms of protein and energy malnutrition.

Kwashiorkor is a severe form of undernutrition, which develops in

individuals on diets with a low protein/energy ratio. The main symptoms
of Kwashiorkor are oedema, wasting, liver enlargement,
hypoalbuminaemia, steatosis and the possible depigmentation of skin
and hair.
Marasmus is the other form of malnutrition, which is caused by
inadequate intake of both protein and energy. It is a form of
severe cachexia with weight loss as a result of wasting in infancy
and childhood. The main symptoms of marasmus are severe wasting,
with little or no oedema, minimal subcutaneous fat, severe muscle
wasting and non-normal serum albumin levels.

Early detection ot PEM : The first indicator of PEM is under-weight

for age. The most practical method to detect this, which can be
employed even by field health workers, is to maintain growth
charts. These charts indicate at a glance whether the child is
gaining or losing weight.

Preventive measures

(a) Primordial level - Health promotion :

1. Measures directed to pregnant and lactating women (education,
distribution of supplements);
2. Promotion of breast-feeding;
3. Development of low cost weaning foods : the child should be
made to eat more food at frequent intervals;
4. Measures to improve family diet;
 5. Nutrition education - Promotion of correct feeding practices;
6. Home economics;
7. Family planning and spacing of births; and
8. Family environment.

(b) Primary level - Specific protection:

1. The child's diet must contain protein and energyrich foods. Milk,
eggs. fresh fruits should be given if possible;
2. Immunization; and
3. Food fortification.

(c) Secondary level - Early diagnosis and treatment:

1. Periodic surveillance;
2. Early diagnosis of any lag in growth;
3. Early diagnosis and treatment of infections and diarrhoea;
4. Development of programmes for early rehydration of children with
diarrhoea;
5. Development of supplementary feeding programmes during
epidemics; and
6. Deworming of heavily infested children.

(d) Tertiary level - Rehabilitation :

1. Nutritional rehabilitation services;
2. Hospital treatment; and
3. Follow-up care.

Q. Food surveillance.
Ans. - Food surveillance implies the monitoring of food safety/food hygiene.
The WHO has defined food safety/food hygiene as "all conditions and
measures that are necessary during the production, processing,
storage, distribution and preparation of food to ensure that it is safe,
sound, wholesome and fit for human consumption.''
 The Declaration of Alma-Ata considered food safety as an essential
component of primary health care.

The importance of surveillance of foodborne diseases has been

underlined in the WHO Sixth General Programme of Work for the
period 1978-1983.

The most important international programme carrying out activities in

the field of food hygiene is the Joint FAO/WHO Food Standard
Programme.

Food is a potential source of infection and is liable to contamination by

microorganisms, at any point during its journey from the producer to
the consumer.

Food hygiene, in its widest sense, implies hygiene in the production,

handling, distribution and serving of all types of food.

The primary aim of food hygiene is to prevent food poisoning and

other food-borne illnesses.

Q. Food fortification.
Ans. - Fortification of food is a public health measure aimed at reinforcing
the usual dietary intake of nutrients with additional supplies to
prevent/control some nutritional disorders.

WHO has defined food fortification as

"the process whereby nutrients are added to foods (in relatively

small quantities) to maintain or improve the quality of the diet of a
group, a community, or a population."
Programmes of demonstrated effectiveness of fortification of food or
water are :
a. fluoridation of water as a preventive of dental caries;
b. iodization of salt for combating the problem of endemic goitre, and
c. food fortification (e.g., vanaspati, milk) with vitamins A and D.

Technology has also been developed for the twin fortification of salt
with iodine and iron.

In order to qualify as suitable for fortification, the vehicle and the

nutrient must fulfil certain criteria :

(a) the vehicle fortified must be consumed consistently as part of the

regular daily diet by the relevant sections of the population or total
population;

(b) the amount of nutrient added must provide an effective supplement

for low consumers of the vehicle, without contributing a hazardous
excess to high consumers;

(c) the addition of the nutrient should not cause it to undergo any
noticeable change in taste, smell, appearance, or consistency; and

(d) the cost of fortification must not raise the price of the food
beyond the reach of the population in greatest need.

Finally, an adequate system of surveillance and control is indispensable

for the effectiveness of food fortification. Food fortification is a long-
term measure for mitigating specific problems of malnutrition in the
community,
Q. Adulteration of foods.
Ans. - Adulteration of foods is an age-old problem. It consists of a large
number of practices, e.g., mixing, substitution, concealing the quality,
putting up decomposed foods for sale, misbranding or giving false
labels and addition of toxicants.

Adulteration results in two disadvantages for the consumer :

1. first, he is paying more money for a foodstuff of lower quality;
2. secondly, some forms of adulteration are injurious to health, even
resulting in death, as for example,
adulteration of mustard oil with argemone oil causing epidemic
dropsy or adulteration of edible oils with trycresyn phosphate (TCP)
resulting in paralysis and death.
Q. Food standards.
Ans. - (a) CODEX ALIMENTARIUS : The Codex Alimentarius Commission, which
is the principal organ of the joint FAO/WHO Food Standards
Programme formulates food standards for international market.
- The food standards in India are based on the standards of the codex
alimentarius.

(b) PFA STANDARDS : Under the Prevention of Food Adulteration Act

(1954) standards have been established which are revised from time
to time by the "Central Committee for Food Standards". The purpose
of the PFA standards is to obtain a minimum level of quality of
foodstuffs attainable under Indian conditions.

(c) THE AGMARK STANDARDS : These standards are set by the

Directorate of Marketing and Inspection of the Government of India.
The Agmark gives the consumer an assurance of quality in accordance
with the standards laid down.

(d) BUREAU OF INDIAN STANDARDS : The ISI mark on any article of

food is a guarantee of good quality in accordance with the standards
prescribed by the Bureau of Indian Standards for that commodity. The
Agmark and ISI standards are not mandatory; they are purely
voluntary. They express degrees of excellence above PFA standards.
Q. Community nutrition programmes. Write a note on Mid-day Meal
Programme.
Ans. - Nutrition programmes : Already discussed.
Q. Socio-economic status and health.
Ans. - Socio-economic status has been defined as the position that an
individual or family occupies with reference to the prevailing average
standards of cultural and material possessions, income, and
participation in group activity of the community.

There are a large number of studies linking social class to incidence of

disease. Income, occupation and education which are the major
components of most measures of social class are also each generally
positively correlated with health status.

Individuals in the upper social classes have a longer life expectancy,

less mortality and a better health and nutritional status than those in
the lower classes.

Diseases also have been shown to affect people at various social levels
differently. For example, coronary heart disease, hypertension, diabetes
all have been shown to have a high incidence in social class I and a
gradual decline in incidence in the other social classes.

Diseases of skin, eye and ears, diarrhoea and dysentery have also
shown a higher incidence in the lower classes, which can be ascribed
to the poor state of physical environment in which they live.

Social class differences in mental illness have also been reported.

Infant mortality, general mortality, maternal mortality are all related to

social class. Infant mortality rate is high (about 70.4 among the lowest
wealth index households and is lowest (about 29.2) among the highest
wealth index households.
Q. Social defence.
Ans. - Social defence is a Relatively new concept in medical sociology. It
covers the entire gamut of preventive, therapeutic and rehabilitative
services for the protection of society from antisocial, criminal or
deviant conduct of man.

Included in this are measures relating to the

1. prevention aind control of juvenile delinquency,
2. eradication of beggary,
3. social and moral hygiene programmes,
4. welfare of prisoners,
5. prison reforms,
6. elimination of prostitution,
7. control of alcoholism,
8. drug addiction,
9. gambling and
10. suicides.

Many States in India have enacted the Children Act for the
prevention and control of juvenile delinquency. Under the Suppression
of Immoral Traffic in Women and Girls Act, services are being provided
for the elimination of prostitution in society.

Social defence is a system developed to defend society against

criminality not merely by treating and defending the offended, but
also by creating such conditions in the community which are conducive
for a healthy and wholesome growth of human life.

The Government of India renamed the: Central Bureau of Correctional

Services as National Institute of Social Defence in 1975. This Institute
is under the Department of Social Welfare.
Q. Doctor-patient relationship.
Ans. - An importaint area of medical sociology is doctor-patient relationship
in which complex social factors are implicated.

The patient comes unbidden to a doctor and enters voluntarily into a

contract in which he agrees to follow the doctor's advice. By virtue of
his technical superiority, knowledge and skill, the doctor exercises an
authoritative role and issues "orders" to his patient.

Some individuals may not be prepared to invest the doctor with full
authority, this may lead to conflict between the doctor and patient.

Besides technical competence, the doctor must know how to

communicate with his patient. In this regard.. three levels of
communication have been described :

(1) Communication on an emotional plane:

(2) Communication on a cultural plane
(3) Communication on a intellectual plane

The doctor who is able to communicate with his patient on these three
planes is bound to give maximum psychological satisfaction to his
patients.

The other qualities which mar the reputation of a doctor are his greed
for money, differential treatment between the rich and poor and lack
of a sympathetic and friendly attitude. The patient can challenge the
doctor's professional adequacy if the doctor does not know how to
communicate.

Patients who do not behave according to the doctor’s expectations are

often labelled as "un-cooperative."
Q. Personality traits.
Ans. - The term "personality" implies certain physical and mental traits which
are characteristic of a given individual; these traits determine to some
extent, the individual's behaviour or adjustments to his surroundings.

A trait is described as tendency to behave in a consistent manner in

variable situations. Human personality is a bundle of traits.

The basic personality traits are established by the age of 6 years.

Some traits, we cultivate (e.g., good manners); some, we may conceal
(e.g., kindliness); and some, we modify depending upon the society in
which we are placed (e.g., sense of humour).

The following are some of the personalilty traits :

-Cheerfulness -Sense of humour
-Loyalty -Honesty
-Good manners -Tactfulness
-Reliability -Kindliness
-Sportsmanship -Willing to help others.

The personality traits we look for in a doctor are kindliness, honesty,

patience, tolerance, perseverance, consciousness, thoroughness and
initiative. It is possible to cultivate these traits.

The Swiss Psychiatrist, Carl Jung divided personalities into 2 types -

(1) Extrovert and (2) Introvert.

The extrovert is a person who is thought to be dashing, practical,

active, showing-off and easily mixes with people.

An introvert is a person who is reserved, shy and generally keeps to

himself. Most people exhibit characteristics of both.