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NUTRITIONAL DEFICIENCY DISORDERS, BALANCED DIET & NUTRITIONAL ANAEMIA

Social & Preventive Medicine - University Exam Answer

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PART A: NUTRITIONAL DEFICIENCY DISORDERS IN INDIA

Classification / Enumeration

NUTRITIONAL DEFICIENCY DISORDERS IN INDIA
│
├── 1. PROTEIN-ENERGY MALNUTRITION (PEM)
│       ├── Kwashiorkor (protein deficiency)
│       ├── Marasmus (calorie deficiency)
│       └── Marasmic-Kwashiorkor (mixed)
│
├── 2. NUTRITIONAL ANAEMIA
│       ├── Iron Deficiency Anaemia (most common)
│       ├── Folate Deficiency (megaloblastic)
│       └── Vitamin B12 Deficiency
│
├── 3. VITAMIN A DEFICIENCY (VAD)
│       └── Xerophthalmia → Keratomalacia → Blindness
│
├── 4. IODINE DEFICIENCY DISORDERS (IDD)
│       ├── Goitre
│       ├── Cretinism
│       └── Intellectual impairment
│
├── 5. VITAMIN D DEFICIENCY
│       └── Rickets (children), Osteomalacia (adults)
│
├── 6. VITAMIN C DEFICIENCY
│       └── Scurvy
│
├── 7. VITAMIN B-COMPLEX DEFICIENCIES
│       ├── Thiamine (B1) → Beriberi
│       ├── Niacin (B3) → Pellagra
│       └── Riboflavin (B2) → Ariboflavinosis
│
└── 8. FLUOROSIS (excess fluoride - endemic in India)
        ├── Dental fluorosis
        └── Skeletal fluorosis

Special note for India: A condition unique to India is Lathyrism (neurolathyrism) - caused by toxic consumption of Lathyrus sativus (Khesari dal). It causes spastic paralysis of lower limbs and is prevalent in Madhya Pradesh, UP, Bihar, and Odisha.

Most Important Nutritional Deficiency Disorders in India (summary table):

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PART B: BALANCED DIET

Definition

"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, carbohydrates 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."

Principles of Constructing a Balanced Diet:

BALANCED DIET - CONSTRUCTION PRINCIPLES
─────────────────────────────────────────────────────
STEP 1: Meet PROTEIN requirement first
        → 10-15% of daily energy intake
        → Sources: pulses, milk, eggs, meat, fish

STEP 2: FATS - limited to 15-30% of daily energy
        → Visible fats (oils, butter) + invisible fats
        → Include essential fatty acids

STEP 3: CARBOHYDRATES - remaining energy (55-75%)
        → Rich in natural fibre
        → Prefer complex carbohydrates

STEP 4: Meet MICRONUTRIENT requirements
        → Vitamins (A, B-complex, C, D, E, K)
        → Minerals (Iron, Calcium, Iodine, Zinc)
─────────────────────────────────────────────────────

RDA for Indians (2020) - Key Values (Park's Table 28):

Components of Balanced Diet (Food Groups):

    ┌─────────────────────────────────────────┐
    │         FOOD PYRAMID (India)            │
    │                                         │
    │      [Fats/Oils/Sugars - USE SPARINGLY] │
    │   [Milk/Dairy | Meat/Fish/Eggs/Pulses]  │
    │      [Vegetables]   [Fruits]            │
    │   [Cereals / Grains - BASE of diet]     │
    └─────────────────────────────────────────┘

1. Cereals and millets - energy, B-vitamins
2. Pulses and legumes - protein, iron, folate
3. Milk and milk products - protein, calcium, B12
4. Meat, fish, eggs - complete protein, iron, B12
5. Vegetables (green leafy) - iron, folate, carotene, vitamin C
6. Fruits - vitamins, antioxidants
7. Fats and oils - fat-soluble vitamins, EFAs
8. Sugar/jaggery - energy (use sparingly)

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PART C: NUTRITIONAL ANAEMIA (Detailed)

Definition (WHO)

"Nutritional anaemia is 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." - WHO

WHO Cut-off Values for Anaemia (Haemoglobin levels):

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Aetiology / Causes of Nutritional Anaemia

CAUSES OF NUTRITIONAL ANAEMIA
│
├── A. DIETARY DEFICIENCY
│       ├── Low iron intake (common in India - cereal-based diet)
│       ├── Poor bio-availability of iron (<5% absorbed from plant foods)
│       ├── Folate deficiency (especially in pregnancy)
│       └── Vitamin B12 deficiency (vegetarian diet)
│
├── B. INCREASED DEMAND
│       ├── Pregnancy and lactation
│       ├── Rapid growth in infancy/adolescence
│       └── Multiple, closely spaced pregnancies
│
├── C. INCREASED LOSSES
│       ├── Menstrual blood loss (women)
│       └── Delivery blood loss
│
├── D. INFECTIONS AND PARASITES
│       ├── Malaria (haemolysis)
│       ├── Hookworm infestation (chronic blood loss)
│       └── Other intestinal parasites
│
└── E. INHIBITORS OF ABSORPTION
        ├── Phytates (in cereals)
        ├── Tannins (in tea/coffee)
        └── Lack of Vitamin C (enhancer)

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The Problem (Magnitude)

• Iron deficiency anaemia is the most widespread micronutrient deficiency affecting all age groups
• 72.7% of children up to 3 years (urban) and 81.2% (rural) are anaemic
• Adolescent girls: 72.6% prevalence (DLHS 2002-04)
• Bihar has highest prevalence (87.6%); Nagaland lowest (44.3%)
• 19% of maternal deaths in India are attributable to anaemia
• Most severely affects: women of reproductive age (15-49 years), children (6-35 months), and low socioeconomic strata

Types of Nutritional Anaemia:

TYPES OF NUTRITIONAL ANAEMIA
│
├── 1. IRON DEFICIENCY ANAEMIA (most common)
│       Type: Microcytic Hypochromic
│       Deficiency: Iron
│       Lab: ↓Hb, ↓MCV, ↓MCH, ↓Serum Ferritin, ↑TIBC
│
├── 2. MEGALOBLASTIC ANAEMIA
│       Type: Macrocytic
│       Deficiency: Folate / Vitamin B12
│       Lab: ↓Hb, ↑MCV, hypersegmented neutrophils
│       Common in: pregnant women (poor income groups)
│
└── 3. DIMORPHIC ANAEMIA
        Type: Mixed (micro + macro)
        Deficiency: Both iron AND folate/B12
        Common in: combined deficiency states

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Detrimental Effects of Anaemia

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Interventions / Management

MANAGEMENT OF NUTRITIONAL ANAEMIA
│
├── SEVERE ANAEMIA (Hb < 10 g/dL)
│       → High dose iron therapy
│       → Blood transfusion if needed
│
├── MODERATE ANAEMIA (Hb 10-12 g/dL)
│       ├── (1) Iron & Folic Acid Supplementation
│       ├── (2) Iron Fortification
│       └── (3) Other strategies
│
└── MILD / PREVENTION
        ├── Dietary modification
        ├── Deworming
        ├── Health education
        └── Treatment of malaria

• National Nutritional Anaemia Prophylaxis Programme (NNAPP) - launched during the 4th Five Year Plan
• Daily IFA tablets to "at-risk" groups: pregnant women, lactating mothers, children under 12 years
• Each tablet: 60 mg elemental iron + 500 mcg folic acid
• Pregnant women: minimum 180 days during pregnancy
• Children 1-5 years: small dose (20mg iron + 100 mcg folate)

• Fortification of common salt with iron (ferric ortho-phosphate / ferrous sulphate with sodium bisulphate)
• Developed at National Institute of Nutrition (NIN), Hyderabad
• Reduces anaemia prevalence significantly over 12-18 months
• Advantages: universal coverage (all segments of population), no special delivery system required
• Commercial production started: 1985

• Dietary habit modification (increase iron-rich foods, vitamin C for absorption)
• Control of parasites (hookworm, malaria)
• Nutrition education

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PART D: ANAEMIA MUKT BHARAT (AMB)

Introduction

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The 6×6×6 Strategy

╔══════════════════════════════════════════════════════════════╗
║           ANAEMIA MUKT BHARAT - 6×6×6 STRATEGY              ║
╠══════════════════════════════════════════════════════════════╣
║                                                              ║
║  6 BENEFICIARIES        6 INTERVENTIONS      6 INSTITUTIONAL ║
║  (Target Groups)                              MECHANISMS     ║
║  ─────────────────   ────────────────────   ───────────────  ║
║  1. Children          1. Prophylactic IFA   1. WIFS          ║
║     (6-59 months)        Supplementation       Programme     ║
║                                                              ║
║  2. Children          2. Periodic           2. NDD           ║
║     (5-9 years)          Deworming             Programme     ║
║                                                              ║
║  3. Adolescents       3. Intensified        3. NCEAR         ║
║     (10-19 years)        BCC Campaign          (National     ║
║                                              Centre for      ║
║  4. Pregnant          4. Testing &           Excellence on   ║
║     women               Treatment using      Anaemia         ║
║                         digital methods       Research)      ║
║  5. Lactating         5. Fortified food     4. Convergence   ║
║     women               promotion            with other      ║
║                                               Ministries     ║
║  6. Women of          6. Addressing         5. Strengthening ║
║     Reproductive         non-nutritional      supply chain   ║
║     Age (15-49 yrs)      causes of                          ║
║                          anaemia            6. AMB Dashboard ║
║                                               (Digital       ║
║                                                Portal)       ║
╚══════════════════════════════════════════════════════════════╝

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6 BENEFICIARIES (Life Cycle Approach):

1. Children (6-59 months)
2. Children (5-9 years)
3. Adolescents - girls and boys (10-19 years)
4. Pregnant women
5. Lactating mothers (0-6 months child)
6. Women of Reproductive Age (WRA) - 15-49 years (non-pregnant, non-lactating)

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6 INTERVENTIONS:

• National Deworming Day (NDD): biannual mass deworming on 10th February and 10th August for children and adolescents (age 1-19 years)
• Pregnant women dewormed in the 2nd trimester via ANC contacts

• Compliance to IFA and deworming
• Appropriate Infant and Young Child Feeding (IYCF)
• Emphasis on complementary foods for children > 6 months
• Increase intake of iron-rich, protein-rich, and Vitamin C-rich foods
• Dietary diversification and food fortification
• Promoting delayed cord clamping

• Digital invasive haemoglobinometer at field level / Sub-Health Centres / HWCs
• Semi-auto analyzer at PHC and above
• Point-of-care treatment following Anaemia Management Protocols

• Food fortification with iron, folic acid, and B12

• Malaria control
• Sickle cell disease screening and management
• Other haemoglobinopathies

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6 INSTITUTIONAL MECHANISMS:

1. WIFS (Weekly Iron Folic Acid Supplementation) Programme
2. NDD (National Deworming Day) Programme
3. NCEAR - National Centre for Excellence and Advanced Research on Anaemia Control (apex national laboratory for anaemia screening and diagnosis; technical inputs for policy and guidelines)
4. Convergence with other Ministries - MoWCD, MoE, MoRD etc.
5. Strengthening supply chain and logistics - auto indents at district level; centralized procurement at state level; IFA and Albendazole as essential drugs
6. AMB Dashboard and Digital Portal - One Stop Shop for anaemia data monitoring

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Historical Timeline of Anaemia Control in India:

1970 ─── National Nutritional Anaemia Prophylaxis Programme (NNAPP)
  │
1991 ─── National Nutritional Anaemia Control Programme
  │
2007 ─── 12 by 12 Initiative
  │
2013 ─── National Iron Plus Initiative (NIPI)
  │
2018 ─── ANAEMIA MUKT BHARAT (Intensified NIPI) ← CURRENT

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Public Health Importance of AMB:

• Anaemia is the 3rd leading cause of DALYs lost for females aged 15-44 years
• Causes GDP loss of 1.18%
• AMB is a landmark initiative as it addresses anaemia through a life cycle approach - from children to women of reproductive age
• It integrates both nutritional and non-nutritional causes
• Digital tools (AMB Dashboard) allow real-time monitoring

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QUICK SUMMARY FLOWCHART

NUTRITIONAL ANAEMIA - OVERVIEW FLOWCHART
┌─────────────────────────────────────────────┐
│           PREDISPOSING FACTORS              │
│  Poor diet → Low iron/folate intake         │
│  Poverty, Parasites, Multiple pregnancies   │
└──────────────┬──────────────────────────────┘
               ↓
┌─────────────────────────────────────────────┐
│              ANAEMIA                        │
│   Hb < WHO cut-off for age/sex/pregnancy    │
└──────────────┬──────────────────────────────┘
               ↓
┌─────────────────────────────────────────────┐
│           CONSEQUENCES                      │
│  ↑Maternal mortality | ↓Work capacity       │
│  LBW babies | ↑Infection susceptibility     │
└──────────────┬──────────────────────────────┘
               ↓
┌─────────────────────────────────────────────┐
│       PREVENTION & CONTROL                  │
│  IFA Supplementation                        │
│  Iron Fortification                         │
│  Deworming (NDD)                            │
│  Dietary Diversification                    │
│  ANAEMIA MUKT BHARAT (2018)                 │
│       ↓ 6×6×6 Strategy                      │
│  Target: ↓3% per year (2018-2022)           │
└─────────────────────────────────────────────┘

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Sources: Park's Textbook of Preventive and Social Medicine (SPM), National Health Mission - Anaemia Mukt Bharat (nhm.gov.in)

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EXAM TIPS - HOW TO PRESENT THIS ANSWER:

• The 6×6×6 AMB table (box format)
• Types of nutritional anaemia (classification box)
• Historical timeline of anaemia control programmes
• WHO Hb cut-off table