Protein energy malnutrition: (PEM)

Dr. Hiren Shekhda

Resident Doctor
Community medicine
Epidemiology Of
Protein Energy
Malnutrition
 INTRODUCTION
• Protein Energy Malnutrition is a potentially fatal body-depletion disorder
characterized not only by an energy deficit due to reduction in
macronutrients but also by a deficit in micronutrients.

• The tragic consequences of malnutrition include death, disability, stunted

mental and physical growth and as a result retarded national socio-
economic development.

• PEM is a self perpetuating disease resulting from imbalance between the

body’s needs and the intake of nutrients.
GLOBAL PREVALENCE
 PROBLEM STATEMENT
• Nearly half of all deaths in children under 5 are attributable to undernutrition;
undernutrition puts children at greater risk of dying from common infections, increases
the frequency and severity of such infections, and delays recovery.

Global Prevalence:
a. Stunting: 22.0% b. Wasting: 6.7%

• In 2020,
1.22 per cent, or more than one in five children under age 5 worldwide had stunted growth
2.Globally, 45.4 million children under five were wasted of which 13.6 million were severely
wasted. This translates into a prevalence of 6.7 per cent and 2.0 per cent, respectively
 PREVALENCE IN INDIA

• Stunting and underweight

• According to NFHS 5, the number of children under 5 years who are stunted (less height-for-
age) in India has come down from 38.4% to 35.5% and the number of children who are 
underweight (less weight-for-age) has come down from 35.8% to 32.1%.
• PEM is primarily due to

(a) An inadequate diet both in quantity & quality.

(b) Infections, diarrhoea, respiratory infections, measles and intestinal

worms.

(c) Contributory factors viz. poor environmental conditions, large family size,
poor maternal health, failure of lactation, premature termination of breast
feeding, and adverse cultural practices relating to child rearing and weaning
such as the use of over-diluted cow’s milk and discarding cooking water
from cereals and delayed supplementary feeding.
 EPIDEMIOLOGICAL DETERMINANTS

AGENT FACTORS:

1. ENERGY DEFICIENCY: Most common cause of under-nutrition

leading to the so-called protein-energy malnutrition. It is usually
associated with deficiency of other nutrients as well.

2. PROTEIN DEFICIENCY

3. OTHER NUTRIENT DEFICIENCIES: When one or more than one

nutrients are inadequate in the food, specific conditions may occur such
as night blindness, beriberi, pellagra, anemia, rickets, etc,..
 HOST FACTORS
1. AGE AND SEX:
a. Infancy and childhood: Particular risk of malnutrition due to high demand for
energy and essential nutrients. Kwashiorkor and Marasmus are seen in
children.
b. Adolescence: Growth rate increases. It is the time of intense physical,
psychosocial and cognitive development. So caloric and protein requirements
are high.
c. Women: More prone for Osteoporosis and fractures as bone loss accelerates
after menopause.
d. Elderly: are also vulnerable to nutritional disorders
e. Old age: Diminished sense of taste and smell, loneliness, physical and mental
handicaps, immobility, chronic illnesses all contribute to malnutrition. The
absorption is also decreased.
PROTEIN ENERGY MALNUTRITION
VULNERABLE GROUPS
2. HABITS , CUSTOMS AND FOOD FADS :

 Nutritionally inadequate and frequently contaminated foods are often

introduced too early or too late. At this time only infectious disease
rates, particularly diarrhoea are highest.
 Early abandonment of breast feeding and greater use of commercial
baby foods which are bulky and low in energy density.
 Early introduction of cereals and vegetables which interfere with the
absorption of breast-milk iron.
 Prolonged exclusive breast-feeding and delayed weaning also causes
growth faltering.
 An Alcoholic mother may give birth to a handicapped and stunted child
with foetal alcohol syndrome.
3. PHYSIOLOGICAL AND PATHOLOGICAL STRESS:

• Requirements of all the nutrients increase during pregnancy and

lactation.
• In chronic diseases, absorption is impaired.
• In liver diseases metabolism of protein and energy sources
interfered with.
• Patients with kidney disease develop protein deficiency.
• Patients with cancer and AIDS have anorexia.

4 . PSYCHOLOGICAL STATE :
• A condition known as anorexia nervosa is commonly seen in
adolescent females.

5. HEREDITY AND CONSTITUTION :

• Diseases of which some are hereditary, result in inability of the
body to digest or absorb certain nutrients.
Eg: cystic fibrosis, coeliac disease, tropical sprue, obesity,
Diabetes Mellitus.
ENVIRONMENTAL FACTORS

1. PHYSICAL FACTORS:
• Geographic location, climate, soil, agricultural
development, population density, etc., determine
nutritional status.
2. SOCIO-ECONOMIC FACTORS:
• Undernutrition is associated with poverty and social
deprivation. Natural calamities, wars, civil disturbances
and population displacement play a part in malnutrition.
3. BIOLOGICAL
FACTORS:
• Malnutrition is worsened
by a child’s parasitic load.

• Infection and Malnutrition

make a vicious cycle.
KWASHIORKOR MARASMUS
 PROTEIN ENERGY
MALNUTRITION
• Protein Energy Malnutrition (PEM) is the deficiency of macronutrients or energy
and protein in the diet.
• It is a nutritional disorder, which affects all the segments of population like
children, women and adult males particularly from the backward and downtrodden
communities.
Different Types of PEM

Clinical forms Sub-clinical forms

o Kwashiorkor Underweight
o Marasmus Wasting
o Marasmic kwashiorkor Stunting
 KWASHIORKOR
• Kwashiorkor is an African word, meaning a "disease of the displaced child",
who is deprived of adequate nutrition.
• Mostly in children between the ages of 1 and 3 years, when they are completely
weaned (taken off the breast).
• The three essential manifestations or signs of kwashiorkor are:
1.Oedema (swelling of feet)
2.Growth failure, and
3.Mental changes.
 CLINICAL SIGNS OF KWASHIORKOR IN DETAIL

Oedema: accumulation of fluid in the tissues.

•Usually begins with a slight swelling in feet gradually spreading up the legs. Later, hands and face
may also have oedema.
Poor growth: Growth retardation is the earliest manifestation.
•The child will be lighter and shorter than its normal peers of same age and weigh about 80% or less
of their normal peers.
•Sometimes, in cases of gross swelling, the body weight may be relatively higher. The child will also
be wasted (thinner). The child's arms and legs will appear thin as a result of wasting.
Mental changes: kwashiorkor child has no interest in the surrounding.
•The child will also be irritable and prefers to stay at one place and in one position.
 OTHER SIGNS WHICH MAY BE PRESENT ARE
Hair changes: In kwashiorkor, the hair loses its healthy sheen and becomes silkier and thinner. It
takes coppery red colour (referred to as 'discoloured hairy).
•You could easily pluck small tufts of hair without causing any pain (referred to as easy pluck
ability) just by passing your hands through the hair.
Skin changes: In many cases, dermatosis (changes in skin) is seen.
•Such changes are common in areas of friction.
Moon face: The cheeks may seem swollen with fluid or fatty tissue and often be slightly
sagging.
Micronutrient deficiencies: Almost all the children manifest anaemia (due to iron deficiency) of
some degree.
•Eye signs of vitamin A' deficiency are also common.
•Manifestations of vitamin B complex deficiency are also noted in many cases.
 MARASMUS
• Marasmus is common in children below the age of 2 years.
• The marasmic children are so weak that they may not have even energy
to cry, which most often is barely audible.
• The child is extremely wasted with very little subcutaneous fat with the
skin hanging loosely particularly over the buttocks.
• Oedema is absent and there are no skin and hair changes.
• However, frequent diarrhoeal episodes leading to dehydration and
micronutrient deficiencies of vitamin A, iron and B-complex are
common.
• Signs and Symptoms of Marasmus
• Extreme muscle wasting - "skin and bones"
• Loose and hanging skin folds
• Old man's or monkey faces
• Absolute weakness
 MARASMIC KWASHIORKOR
• Sometimes, in areas where PEM is common, malnourished children exhibit the features of both
kwashiorkor and marasmus. Such changes could occur during the transition from one form of
severe PEM to another.
• These children will have extreme wasting of different degrees (representing marasmus) and
also oedema (a sign of kwashiorkor).
• They may also man
• Signs and symptoms of Marasmic Kwashiorkor
• Extreme muscle wasting - "skin and bones"
• Loose and hanging skin folds
• Old man's or monkey's face
• Absolute weakness
• Oedema
Classification & clinical
features of PEM
 RECOGNISING A
MALNOURISHED CHILD
• Various methods are available.

• Most important method is regular weighing coupled with construction of

weight chart. Initial chart was designed by David Morley by using weight for
age as tool.

• To assess the nutritional status of the child the growth curve of child is
compared with WHO standard growth curve.
OTHER METHODS WHICH MAY BE OF HELP AT
COMMUNITY LEVEL :

1.WEIGHT FOR HEIGHT

2.HEIGHT FOR AGE

3.MIDARM CIRCUMFERENCE

4.MIDARM CIRCUMFERENCE FOR HEIGHT

5.TRICEPS SKIN FOLD THICKNESS

 CLASSIFICATION OF PEM

VARIOUS CLASSIFICATIONS ARE

1. GOMEZ CLASSIFICATION

2. IAP CLASSIFICATION

3. WATERLOW’S CLASSIFICATION

4. CLASSIFICATION BASED ON ARM CIRCUMFERENCE

5. WELCOME TRUST CLASSIFICATION

 GOMEZ CLASSIFICATION

• BASIS: CHILD WEIGHT COMPARED WITH WEIGHT OF

NORMAL CHILD OF SAME AGE

• NORMAL REFERENCE CHILD IS 50th CENTILE OF

BOSTONS STANDARD

• CALICULATED BY:

wt. for age% = wt. of child x 100

wt. of normal child of same age
 WEIGHT FOR AGE% NUTRITIONAL STATUS
90-110% NORMAL
75-89 % MILD MALNUTRITION
60-74 % MODERATE MALNUTRITION
<60 % SEVERE MALNUTRITION

ADVANTAGE : IT HAS PROGNOSTIC VALUE

DISADVANTAGES:

1.CUT OFF POINT 90% OF REFERENCE IS HIGH.

2.UNABLE TO DIFFERENCIATE THE LOW WEIGHT

DUE TO CHRONIC UNDER NUTRITION OR ACUTE
EPISODE OF MAL NUTRITION.
 INDIAN ACADEMY OF PAEDIATRICS
CLASSIFICATION

BASIS: SAME AS GOMEZ CLASSIFICATION

ACCORDING TO THIS CLASSIFICATION

>80% NORMAL
70-80% 1st DEGREE MALNUTRUITION
60-70% 2nd DEGREE MALNUTRITION
50-60% 3rd DEGREE MALNUTRITION
<50% 4th DEGREE MALNUTRITION
 WATER LOW’S CLASSIFICATION

BASIS:DEPENDS ON TWO FACTORS

1.HEIGHT FOR AGE (nutrition over a long period/chronic)

2.WEIGHT FOR HEIGHT (acute/ Recent alteration of nutritional

status)

H/A | W/H | >m-2SD | <m-2SD

-------------------------------------------------------------------------------
>m-2SD | NORMAL | WASTED
--------------------------------------------------------------------------------
<m-2SD | STUNTED | WASTED&STUNTED
THIS CLASSIFICATION DEFINES TWO GROUPS OF PEM

1.Drop in height for age ratio indicates Chronic under nutrition

2. For a normal height weight for height ratio is low indicates acute episode of
malnutrition

CALCULATION;

wt% = wt of child x 100

ht wt of normal child of same ht

ht% = ht of child x 100

age ht of normal child at same age
 DETERMINATION OF NUTRITIONAL
STATUS
NUTRITIONAL % of ht/age % of wt/ht
STATUS
NORMAL >95% >90%

MILD 87.5-95% 80-90%

MALNUTRITION

MODERATE 80-87.5% 70-80%

MALNUTRITION

SEVERE <80% <70%

MALNUTRITION
 CLASSIFICATION BASED ON ARM
CIRCUMFERENCE

CIRCUMFERENCE OF ARM MEASURED BY SHAKIR’S

TAPE

READINGS COLOUR NUTRITIONAL STATUS

>13.5cm GREEN NORMAL
12.5-13.5cm YELLOW BORDER LINE
<12.5cm RED MALNUTRITION

ADVANTAGE: IT IS HELPFUL IN QUICK SURVEYS IN

COMMUNITY.
 WELCOME TRUST CLASSIFICATION

BASIS:BASED ON 2 FACTORS
1.WEIGHT
2.OEDEMA

Wt% OF STANDARAD OEDEMA PRESENT OEDEMA ABSENT

60-80% KWASHIORKOR UNDER WEIGHT

<60% MARASMUS & MARASMUS

KWASHIORKOR
ADVANTAGE: IT IS SIMPLE AND HAS PRACTICAL
APPROACH

DISADVANTAGES:

1.CHRONICITY OF DISEASE IS NEGLECTED.

2.NOT APPLICABLE IF AGE IS DOUBTFUL.

 CLINICAL FEATURES

PEM HAS 2 CLINICAL TYPES

1.MARASMUS
2.KWASHIORKAR

MARASMUS

• MARKEDLY WASTED EMACIATED MUSCLE

• LOOSE FOLDS OF SKIN WRAPED OVER BONE
• LOSS OF SUBCUTEANEOUS FAT
• BODY wt <60% OF NORMAL WEIGHT
• ANXIOUS & HUNGRY
• SKIN MORE PRONE TO INFECTIONS
• HYPOPIGMENTED HAIR
KWASHIORKAR
• SEVERE FATAL FORM OF PEM
• PROTEIN INTAKE IS INSUFFICIENT
• SEEN AT 8 MONTHS TO 2yrs OF AGE

ESSENTIAL
CLINICAL FEATURES.
FEATURES
• RETARDED GROWTH

• OEDEMA

• MUSCLE WASTING
 USUAL FEATURES

• INACTIVE,IRRITABLE,APATHETIC
• MOON FACE APPEARANCE
• HYPOPIGMENTED HAIR WITH FLAG SIGN
• DECREASED APPETITE
• PRONE TO INFECTIONS

• SKIN CHANGES: PELLAGROID TYPE/FLAKING PAINT RASH

• ENLARGED FATTY LIVER

Prevention of Protein Energy
Malnutrition
In Developing countries it is a huge challenge.
Underlying causes numerous & complex.
No Single, Universal, Cheap, Sustainable Strategy.
Levels of Prevention:
 

Primary Prevention:
Health Promotion
Specific protection
 
Secondary Prevention:
Early diagnosis & treatment
 
Tertiary prevention:
Rehabilitation.
 HEALTH PROMOTION
Measures directed to pregnant and lactating
women
Promotion of breast feeding.
Low cost weaning foods.
Improve family diet.
Nutrition education
Home economics
Family planning & spacing of births
Family environment.
Relative Protein Additional allowances
during pregnancy and
value of some foods. lactation
 
Nutrients per 100gms Food items During During
 

Food pregnancy lactation

Kcal Protein (g)
 

Fish 100 20.0 Cereals 35.g 60.g

Milk 67 3.2
Pulses 15.g 30.g
Dhal 350 21.0

Rice 350 7.0 Milk 100.g 100.g

Potato 100 1.6
Fat -- 10.g
Banana 100 1.0
Sugar 10.g 10.g
Tapioca 160 0.7
 Specific Protection
Protein & energy rich foods.
Eg: - Pulses, Milk, Eggs, Fresh Fruits.
Immunization.
Food fortification.

Early diagnosis & Treatment:

Periodic surveillance.
Early diagnosis of any lag in growth.
Early diagnosis & treatment of infections.
Early rehydration.
Supplementary feeding programmes.
Deworming.
 Rehabilitation
Aim:
Achieve freedom from residual or recurrent nutritional
handicap.
Cost effective method.
Active, fruitful, cross fertilization of treatment & prevention.
Nutritional rehabilitation centers:
Motto - Get well & Stay well.
Adequate dietary treatment
Medical & General care services
Education of Mothers.
Indications:
Moderate to severe uncomplicated cases.
Discharged from hospital after initial treatment.
 At Family Level
Exclusive breast-feeding:
Indian mothers secrete average of 600ml of breast milk per
day
1.2 gm % proteins in first year of lactation
100ml of breast milk – 71 kcal.

Nutrition supplements – above six months

Complimentary foods – cereals & legumes.
Immunization
Iatrogenic restriction of feeding should be discouraged.
Adequate spacing of births.
 AT COMMUNITY LEVEL
Early detection of malnutrition & intervention

Growth Monitoring:

Advantages:
Diagnostic tool
Planning and policymaking
Educational tool
Tool for action
Evaluation
Tool for teaching
Integrated health package
Nutrition education
Vigorous promotion of family planning
Income generation activities
Promotion of education & literacy in the community
Technological Measures:
Iodination of common salt.
Prevention of Night blindness.
Distribution of Iron folate Tablets.

3 groups of community
leaders were trained
as health agents.
 AT NATIONAL LEVEL
Nutrition supplementation:
Objectives-
 Treat & rehabilitate severely malnourished
 Improve General health & well being of children
 Increase the resistance to infection
 Accelerate the physical & Mental growth of children
 Improve academic performances

Nutritional Surveillance:
Define character and magnitude
Analyses causes
Select appropriate strategies
Assist Govt. in formulating nutritional policy.
Help Govt. in planning, development & Implementation
Nutritional Planning
Long term planning
Increasing purchasing power of people
More rewarding and permanent
National Nutrition programmes
Vitamin A prophylaxis programme
National Anemia control programme
Mid-day Meal programme
Balwadi nutrition programme

Aim:
Improve in General health
Quality of life
Infection control
Effective Nutritional education & supplementations.
 AT INTERNATIONAL LEVEL

• INTERNATIONALCO-OPERATION

• ACCUTE EMERGENCIES
CAUSED BY FLOODS
AND DROUGHTS
• INTERNATIONAL AGENCIES
FAO
UNICEF
WHO
WORLD BANK
• BATTLE AGAINST
MALNUTRITION
ICDS – INTEGRATED CHILD DEVELOPMENT
SERVICES
MULTI SECTORIAL OPERATIVE
PROGRAMME
BENEFICIARIES – CHILDREN’S < 6 YEARS.
PREGNANT AND LACTATING WOMEN
OTHER WOMEN – 15-44 YEARS
Hospital Management
Aim:
Reduce mortality to minimum
Produce most rapid recovery
Principles:
Use of high protein & energy diet
Maintaining fluid & Electrolyte balance
Control of accompanying infections.
WHO recommended laboratory tests:
Blood Glucose
Blood Smears
HB
Urine examination & Culture.
Stool examination
Serum Albumin
HIV test
Electrolytes

Other tests
Detailed dietary history
Growth measurements
Body Mass Index
Complete physical examination.
Assessment and follow up
 Community level diagnosis
Is he malnourished ?
If yes, how severe ?
Does he have Other associated diseases ?
Has any rule of good nutrition been broken
Why was the rule broken ?
How could his mother feed him ?
What is available ?
Does he know value of available foods ? start on
diet,rehabilitate,educate the parents provide moral
assistance to the mother
Look to the Growth Chart
If rising – healthy
Staying same – in danger
Falling – in great danger
 CHILDREN AT GREATER RISKS
Inadequate growth
Early weaning
Children with frequent infections
Children from families with socio economic problems
E.g.:- Unmarried mothers
Families abandoned by the fathers
Unemployed fathers.
NUTRITION
PROGRAMMES IN
INDIA

Dr. Hiren Shekhda

• Under-nutrition prevalent in India is both macronutrient deficiency (protein-energy
malnutrition) as well as micronutrient deficiency (notably deficiencies in iron, iodine,
vitamin A and zinc).
• Nutrition programs in India are directed against general malnutrition and at specific
nutritional deficiencies.
• Programs directed against general malnutrition:
• Integrated Child Development Services Scheme
• Nutrition program for adolescent girls which runsplatform
• Cooked Mid-day Meal Program
• Antyodaya Anna Yojana
•Annapurna Scheme
•Applied Nutrition Program
•Special Nutrition Program, Balwadi Nutrition Program, Tamil Nadu
Integrated Nutrition Program and Wheat based Supplementary Nutrition
Program, which are now part of ICDS.
•Programs directed against specific nutritional
deficiencies:
•Vitamin A Prophylaxis Program
•National Nutritional Anaemia Prophylaxis Program.
•Anemia Mukt Bharat
•National Iodine Deficiency Disorders Control Program.
• Mid-day Meal Program (under Department of School Education, Ministry of Human Resource
Development)
• It was started in 1962 and launched again in 1995 as National Program of Nutritional Support
to Primary Education (NP-NSPE). In 2004 it was revised to provide cooked mid-day meals to
children in classes I-V of government, government aided and local body schools, Employment
Guarantee Scheme (EGS) and Alternative Innovative Education (AIE) centers. Currently, it
covers primary and upper primary school children in the entire country.
 OBJECTIVES:

• Improve the nutritional status of school children.

• Encourage poor children to attend school more regularly and help them
concentrate on classroom activities

• Provide nutritional support to children of primary stage indrought affected

areas during summer vacation.
 IMPLEMENTATION

• The mid-day meal scheme provides cooked meal with the following calorific values along with
adequate quantities ofmicronutrients-
• (1) Primary school children: 450 calories and 12 g protein per school day per child;
• (2) Upper primary school children: 700 calories and 20 g of protein per school day per child.
Mid-day meal is also provided during summer vacation in drought affected areas.
• Norms for engagement for cook-cum-helpers are as follows
• (1) One cook-cum-helper for schools up to 25 students;
• (2) Two for schools with 26-100 students;
• (3) One additional for every 100 students thereafter.
• Antyodaya Anna Yojana
(under Ministry of Agriculture,Consumer Affairs, Food and Public
Distribution)

• It was launched in December 2000 with the provision to provide food grains in
highly subsidized rates to 1 crore poorest families out of the BPL families
identified under the Targeted Public Distribution System.
• Each family will get 35 kg of food grains per month at 12/kg for wheat and 3/kg
for rice.
• It was extended to include all eligible BPL families in 2009 with priority to
families of HIV-positive persons in the AAY list.
• Annapurna Scheme
(under Ministry of Agriculture, Consumer Affairs, Food and Public
Distribution)

• This scheme covers the destitute senior citizens 65 years and above who should
be getting pension under the Indira Gandhi National Old Age Pension Scheme
but are not getting.

• These individuals are given 10 kg of food grains per person per month free of
cost.
 VITAMIN A PROPHYLAXIS PROGRAM
(UNDER MINISTRY OF HEALTH AND
FAMILY WELFARE)

•The program was started in 1970 with the objective to reduce the prevalence of vitamin A
deficiency disorders from 0.6 to 0.5%.
•Strategies
•Health education to encourage appropriate infant and young child practices including
feeding of colostrum
•Early detection and treatment of infections
•Administration of nine mega doses of vitamin A to children every 6 months, starting from
9 months till 5 years of age (1 lakh IU at 9 months with measles immunization, 2 lakhs IU
at 16-18 months with DPT booster, followed by 2 lakhs IU every 6 months till 5 years of
age). In some states there are 2 months in the year fixed for vitamin A administration along
with other child health services.
• Activities for sick children:

• All children with xerophthalmia to be treated at health facilities

• All children having measles, to be given one dose of vitamin A if they have not
received it in the previous month

• All cases of severe malnutrition to be given one additional dose of vitamin A.

 NATIONAL NUTRITIONAL ANEMIA
PROPHYLAXIS PROGRAM
• It was launched in 1972 with the aim to prevent nutritional anemia in children
and pregnant and lactating women. Currently the program is part of RMNCH+A,
and provides iron and folic acid supplementation to various age groups as given
in Table
• Biannual deworming is advised for all individuals over 12 months of age. Single
dose albendazole in a dose of 200 mg for 12-24 months and 400 mg thereafter is
administered once in 6 months. Nutrition education to improve overall dietary
intake as well as consumption of iron and folate rich foods is also done under the
program.

• National iron plus initiative (NIPI):

• The NIPI was started under RMNCH+A to control iron deficiency anemia
comprehensively across all life stages and provide minimum service package for
prevention of nutritional anemia at all levels of health care, including folic acid
supplementation from the preconception phase to prevent neural tube defects and
other congenital anomalies.
• Weekly iron and folic acid supplementation (WIFS):

The WIFS is a national scheme which aims to cover all children studying in
classes I to XII of government, government aided and municipal schools. The
main activities in this scheme are:

• Supervised administration of weekly iron and folic acid

• Supplements Screening of target groups for moderate and severe anemia and
referral to an appropriate health facility

• Biannual deworming and Information and counseling for improving

• Preventive actions for intestinal worm infestation.

 INTERVENTIONS
1.Prophylactic Iron and Folic Acid supplementation

2.Deworming

3.Intensified year-round Behaviour Change Communication Campaign (Solid

Body, Smart Mind) focusing on four key behaviours including Ensuring delayed
cord clamping after delivery (by 3 minutes) in health facilities

4.Testing and treatment of anemia, using digital methods and point of care
treatment, with special focus on pregnant women and school-going adolescents

5.Mandatory provision of Iron and Folic Acid fortified foods in government-funded

public health programmes

6.Intensifying awareness, screening and treatment of non-nutritional causes of

anemia in endemic pockets, with special focus on malaria, haemoglobinopathies
 BENEFICIARIES

1. Children (6–59 months)

2. Adolescent girls (15–19 years)
3. Adolescent boys (15–19 years)
4. Women of reproductive age
5. Pregnant women
6. Lactating Women
 NATIONAL IODINE DEFICIENCY DISORDERS CONTROL
PROGRAM (UNDER MINISTRY OF HEALTH AND FAMILY WELFARE)
• The National Goitre Control Program was launched in 1962 and renamed in 1992
to address the disorders that are caused by iodine deficiency.
• The goal of the program is to reduce the prevalence of iodine deficiency disorders
to below 10% in endemic districts of the country by 2000. Since this was
achieved, the goal was modified to reduce the prevalence of IDD to below 5%.
• The activities under the program are:
• Surveys to assess the magnitude of the iodine deficiency disorders in districts.
• Supply of iodized salt in place of common salt.
• Resurveys to assess iodine deficiency disorders and the impactof iodized salt
after every 5 years in districts.
• Laboratory monitoring of iodized salt and urinary iodine excretion.
• Health education and publicity.
 NATIONAL PROGRAM FOR
PREVENTION AND CONTROL OF
FLUOROSIS
• Fluorosis is caused by excess intake of fluorides through drinking
water/food products/industrial pollutants, over a long period, resulting in
major health disorders like dental fluorosis, skeletal fluorosis and
nonskeletal fluorosis.
• These harmful effects are permanent in nature and irreversible. The
desirable limit of fluoride as per Bureau of Indian Standards (BIS) is 1 ppm
(1 mg per liter).
• Fluoride may be kept as low as possible as high fluoride is injurious to
health. To combat this problem, a 100% centrally approved NPPCF was
launched in 2008-09.
• Goal: Prevention and control of fluorosis cases in the country.
 ZINC SUPPLEMENTATION

• Zinc supplementation has been shown to reduce the duration and severity
of episodes of acute diarrhea.

• Zinc supplementation is used as an adjunct to ORS under the national

program, to control acute diarrheal diseases.

• The dose of zinc administration is 10 mg per day in infants 2-6 months of

age (dispersible tablet to be given in expressed breast milk) and 20 mg per
day in 6 months to 5 years of age, for 14 days.