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Food Fortification in PSM (Preventive & Social Medicine)

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Definition

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Programmes of Demonstrated Effectiveness

• Iodized salt is now widely used in most countries, including India (mandatory under law).
• Technology has been developed for twin (double) fortification of salt with both iodine and iron to tackle two deficiencies simultaneously.

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Criteria for a Suitable Vehicle and Nutrient (WHO, Park's 25th criterion)

1. (a) Consumption pattern - The vehicle must be consumed consistently as part of the regular daily diet by the relevant (or total) population sections targeted.
2. (b) Safe dose range - The amount of nutrient added must provide an effective supplement for low consumers, without contributing a hazardous excess to high consumers.
3. (c) Organoleptic acceptability - The addition must not cause any noticeable change in taste, smell, appearance, or consistency of the food.
4. (d) Affordability - The cost of fortification must not raise the price of the food beyond the reach of the population in greatest need.

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Additional Requirement

• An adequate system of surveillance and control is indispensable for the effectiveness of food fortification programmes.
• Food fortification is a long-term measure for mitigating specific problems of malnutrition in the community.

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Types of Fortification (Global Classification)

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Common Examples in India (PSM Context)

1. Iodized salt - Standard salt fortified with potassium iodate (30 ppm at production level; 15 ppm at consumer level) to combat Iodine Deficiency Disorders (IDD). Mandated by Prevention of Food Adulteration Act.
2. Vanaspati (hydrogenated fat) with Vitamins A & D - Required by the Prevention of Food Adulteration Rules to contain minimum Vitamin A (25 IU/g) and Vitamin D (2.5 IU/g).
3. Fluoridation of water - Optimal fluoride level: 0.5-0.8 mg/L (ppm) in India (due to warmer climate; 1 ppm in temperate climates) to reduce dental caries without causing fluorosis.
4. Twin fortification of salt (TFS) - Double fortified with both iodine and iron - addresses the co-existence of IDD and iron-deficiency anaemia; developed by NIN (National Institute of Nutrition), Hyderabad.
5. Folic acid in cereal flour - Adopted in many countries to prevent neural tube defects (NTDs) in neonates.

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Advantages of Food Fortification

• Reaches a large population without requiring individual behaviour change
• No change in food habits needed
• Cost-effective and sustainable over the long term
• Can be implemented rapidly through existing food supply chains
• Does not require individual compliance (as opposed to supplementation)

Limitations / Disadvantages

• Difficult to reach populations who do not consume the vehicle food (e.g., remote tribal populations not using commercial salt)
• Risk of over-fortification in high consumers of the vehicle
• Requires robust quality control and surveillance systems
• May not address multiple concurrent deficiencies with a single vehicle
• Higher cost may limit access in the most vulnerable populations

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Fortification vs. Supplementation vs. Dietary Diversification

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Botulism in PSM (Preventive & Social Medicine)

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Overview

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Classification of Food Poisoning (PSM Context)

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Aetiology (Agent)

• Agent: Exotoxin of Clostridium botulinum
• Types: Generally Type A, B, or E (Types A & B most common; Type E associated with fish)
• At least 7 antigenic toxin types (A-G) are known; an 8th type (H) has been reported
• C. botulinum is an anaerobic, spore-forming, gram-positive bacillus

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Source / Reservoir

• The organism is widely distributed in soil, dust, and the intestinal tract of animals
• Enters food as spores
• Foods most frequently responsible:
  • Home-canned/home-preserved vegetables
  • Smoked or pickled fish
  • Home-made cheese
  • Similar low-acid foods stored under anaerobic conditions
  • Honey (source of spores in infant botulism)

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Incubation Period

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Mechanism of Food Poisoning

• The toxin is preformed in food ("intradietetic") under suitable anaerobic conditions
• After absorption, botulinum toxin blocks release of acetylcholine (ACh) at the neuromuscular junction (presynaptic blockade)
• Acts on the parasympathetic nervous system
• Produces a descending flaccid paralysis - irreversible binding to presynaptic terminals
• Immunity does NOT develop - patients who recover do not develop antitoxin in the blood

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Clinical Features

Neurological (Prominent):

• Dysphagia (difficulty swallowing)
• Diplopia (double vision)
• Ptosis (drooping eyelids)
• Dysarthria (difficulty speaking)
• Blurring of vision
• Muscle weakness - descending, symmetric, flaccid
• Quadriplegia (in severe cases)

Key Distinguishing Features:

• Fever is generally absent
• Consciousness is retained (patient fully alert)
• GI symptoms are very slight (unlike other food poisonings)
• Condition is frequently fatal - death occurs 4-8 days later due to respiratory or cardiac failure

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Types of Botulism

Infant Botulism (Special):

• Occurs predominantly in infants < 6 months
• Preceded by or begins with constipation
• Features: decreased movement, loss of facial expression, poor feeding, weak cry, diminished gag reflex, ocular palsies, loss of head control
• Due to in vivo toxin production in the gut (unlike food-borne botulism)
• Honey is an avoidable source - honey should NOT be given to infants < 1 year

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Diagnosis

• Toxin neutralization bioassay in mice (gold standard)
• In vitro mass spectrometry assay
• Specimens: serum, stool, enema fluid, gastric aspirate, suspected food
• EMG: Incremental increase of evoked muscle potentials at high-frequency (20-50 Hz) nerve stimulation (unlike Myasthenia Gravis which shows decrement)
• Treatment should NOT wait for lab confirmation - start on clinical suspicion

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Treatment

1. Meticulous supportive care - especially respiratory support (mechanical ventilation if needed); recovery may take weeks to months
2. Antitoxin:
   • Should be given to all individuals who partook of the suspected food (prophylaxis)
   • Dose: 50,000 to 100,000 units IV
   • Antitoxin is of no avail if toxin is already fixed to nervous tissue
   • For infant botulism: BabyBIG (Human Botulism Immune Globulin IV) - licensed FDA
   • For all forms including adults: Heptavalent BAT (equine-derived, available via CDC)
3. Guanidine hydrochloride (oral): 15-40 mg/kg body weight - shown to reverse the neuromuscular block; useful adjunct when combined with good medical and nursing care
4. Active immunization with botulinum toxoid is also available (for prevention in high-risk persons)

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Prevention and Control

Key point: The toxin is thermolabile - destroyed at 100°C for a few minutes. However, the spores are heat-resistant and require autoclaving (121°C, 15 min) for destruction.

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Comparison with Other Food Poisonings (PSM Exam Favourite)

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Reasons (Causes) of Muscle Paralysis

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The Motor Pathway (Overview)

Motor Cortex (UMN)
      ↓
Internal Capsule / Corticospinal Tract
      ↓
Spinal Cord (UMN ends / LMN begins at anterior horn)
      ↓
Anterior Horn Cell (LMN cell body)
      ↓
Peripheral Nerve (LMN axon)
      ↓
Neuromuscular Junction (NMJ)
      ↓
Muscle Fibre

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Level 1 - Upper Motor Neuron (UMN) Lesions

Signs of UMN Lesions:

Note: In acute UMN lesions (e.g., stroke, spinal shock), initial presentation is flaccid with decreased tone and reflexes - spasticity develops over hours to weeks.

Causes by Location:

A. Cerebral Cortex / Cerebral Hemisphere

• Stroke (ischaemic or haemorrhagic) - most common cause of hemiplegia
• Brain tumour (primary or metastatic)
• Traumatic brain injury
• Brain abscess
• Multiple sclerosis (demyelinating plaques)
• Encephalitis
• Cerebral palsy (perinatal hypoxic-ischaemic injury)

B. Internal Capsule

• Lacunar infarct (pure motor hemiplegia - classic)
• Hypertensive haemorrhage

C. Brainstem

• Brainstem stroke - produces crossed hemiplegia (ipsilateral cranial nerve + contralateral body weakness)
• Brainstem tumour (e.g., glioma)
• Multiple sclerosis

D. Spinal Cord (UMN + LMN features at different levels)

• Trauma / spinal cord injury → quadriplegia (cervical) or paraplegia (thoracic/lumbar)
• Transverse myelitis
• Multiple sclerosis (cord plaques)
• Spinal cord compression (disc prolapse, tumour, abscess, haematoma)
• Motor neuron disease (ALS) - both UMN and LMN affected
• Syringomyelia
• Subacute combined degeneration (Vitamin B12 deficiency)

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Level 2 - Lower Motor Neuron (LMN) Lesions

Signs of LMN Lesions:

Causes:

A. Anterior Horn Cell (Motor Neuron)

• Poliomyelitis - classic acute flaccid paralysis; destruction of anterior horn cells
• Amyotrophic Lateral Sclerosis (ALS) - LMN + UMN combined
• Spinal Muscular Atrophy (SMA) - genetic degeneration of anterior horn cells
• West Nile virus - acute flaccid paralysis
• Progressive Muscular Atrophy - pure LMN variant

B. Nerve Root (Radiculopathy)

• Disc herniation / Prolapsed intervertebral disc (PIVD) - L4-L5, L5-S1 most common
• Spondylosis
• Tumour compressing nerve root
• Guillain-Barre Syndrome (GBS) - acute ascending demyelinating polyneuropathy (affects roots + peripheral nerves)

C. Peripheral Nerve (Neuropathy / Mononeuropathy)

• Trauma / nerve injury (cutting, compression, stretch)
• Compression neuropathies:
  • Radial nerve palsy ("Saturday night palsy") - wrist drop
  • Common peroneal nerve palsy - foot drop
  • Ulnar nerve palsy - claw hand
  • Carpal tunnel syndrome (median nerve)
• Guillain-Barre Syndrome (GBS) - most common acute paralytic polyneuropathy
• Diabetic neuropathy
• Vasculitis / mononeuritis multiplex
• Leprosy - thickened peripheral nerves → mononeuropathy multiplex
• Diphtheria - demyelinating polyneuropathy (toxin-mediated)
• Lead poisoning - wrist drop, predominantly motor neuropathy
• Hereditary motor-sensory neuropathy (Charcot-Marie-Tooth disease)

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Level 3 - Neuromuscular Junction (NMJ) Disorders

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Level 4 - Muscle Disorders (Myopathies)

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Special Patterns of Paralysis and Their Localisation

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UMN vs LMN vs NMJ vs Myopathy - Quick Comparison

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ICDS (Integrated Child Development Services) in PSM

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Introduction

• ICDS = Integrated Child Development Services
• Started: 1975, in pursuance of the National Policy for Children
• India's largest and most unique programme for early childhood care and development
• It is designed both as a preventive and developmental effort
• The programme has a strong nutrition component - supplementary nutrition, Vitamin A prophylaxis, and iron and folic acid distribution

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Administrative Unit

• Preference given to areas inhabited by backward tribes, drought-prone areas, and areas with rampant nutritional deficiencies
• By end of 2019: ~7,075 ICDS projects and 13.77 lakh Anganwadi Centres / Mini-AWCs functional in the country

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Beneficiaries

Note: Below Poverty Line (BPL) is NOT a criterion - the scheme is universal.

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Objectives (5 Objectives)

1. (a) To improve the nutritional and health status of children in the age group 0-6 years
2. (b) To lay the foundations for proper psychological, physical and social development of the child
3. (c) To reduce mortality, morbidity, malnutrition and school drop-out
4. (d) To achieve effective coordination of policy and implementation among various departments working for child development
5. (e) To enhance the capability of the mother to meet the nutritional and health needs of the child through proper nutrition and health education

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Package of Services (6 Services)

Services 2, 3, and 4 (immunization, health check-up, referral) are provided through public health infrastructure - sub-centres, PHC, and CHC.

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Services Provided to Each Beneficiary

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Delivery of Services (Details)

1. Supplementary Nutrition

• Children coming to AWC: morning snack (milk/banana/egg/seasonal fruit/micronutrient-fortified food) + hot cooked meal
• Children < 3 years and pregnant/lactating mothers: "Take Home Ration" (THR)

• 1st degree: Nutrition education + health education to mother
• 2nd and 3rd degree: Supplementary/therapeutic food
• 4th degree: Recommended hospitalization

2. Nutrition and Health Education

• Given to all women aged 15-45 years (priority to nursing and expectant mothers)
• Imparted through organized courses in village during home visits by Anganwadi workers

3. Immunization

• Children: Against 9 vaccine-preventable diseases
• Expectant mothers: Tetanus immunization

4. Health Check-up

• Antenatal care for expectant mothers (minimum 3 physical examinations)
• Postnatal care for nursing mothers and newborns
• Care of children under 6 years including:
  1. Weight and height recorded at periodical intervals
  2. Watch over developmental milestones
  3. Immunization
  4. General check-up every 3-6 months
  5. Treatment for common illnesses (diarrhoea, dysentery, RTI)
  6. Deworming
  7. Prophylaxis against Vitamin A deficiency and anaemia
  8. Referral of serious cases
• Iron, folic acid tablets, and protein supplements given to expectant mothers

5. Non-formal Pre-school Education

• For children 3-6 years at the anganwadi in each village (~1000 population)
• Objective: Develop desirable attitude, values and behaviour
• Uses locally produced, inexpensive toys and materials

6. Medical Referral Services

• Serious cases referred to hospitals/appropriate institutions for special care

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Infrastructure and Functionaries

Anganwadi Centre (AWC) Norms:

• 1 AWC for 300-800 population (previously stated as 400-800)
• 1 Mini-AWC for 150-300 population (previously 150-400)

Key Personnel:

• Provides direct link to children and mothers
• Assists CDPO in survey of community and beneficiaries
• Organizes non-formal education sessions
• Provides health and nutrition education to mothers
• Assists PHC staff in providing health services
• Maintains records of immunization, feeding and pre-school attendance

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Schemes for Adolescent Girls under ICDS

1. Kishori Shakti Yojana (KSY): Targets girls 11-18 years; addresses self-development, nutrition, literacy, numerical and vocational skills; implemented using ICDS infrastructure
2. Nutrition Programme for Adolescent Girls (NPAG): Pilot in 51 identified districts; targets undernourished girls (< 30 kg in 11-15 yrs; < 35 kg in 15-19 yrs); provides 6 kg free food grain/month
3. SABLA (Rajiv Gandhi Scheme for Empowerment of Adolescent Girls): For age group 11-18 years to improve nutritional and health status
4. IGMSY (Indira Gandhi Matritva Sahyog Yojana): Conditional cash transfer to pregnant and lactating mothers to improve their nutritional and health status

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Poshan Abhiyan (National Nutrition Mission)

• Launched: 18th December 2017 by Government of India
• Coverage: All 36 states/UTs for 3 years starting 2017-18
• Ensures convergence of various programmes (Anganwadi services, PMMVY, Janani Suraksha Yojana, NHM, Swachh Bharat Mission etc.)

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Impact of ICDS Programme

• Increased birth weight
• Reduced incidence of malnutrition
• Increased immunization coverage
• Reduced infant and child mortality rate in covered areas

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Summary - Key Numbers to Remember

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Poshan Abhiyan in PSM

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Introduction

• Full name: POSHAN Abhiyan = PM's Overarching Scheme for Holistic Nourishment
• Also known as the National Nutrition Mission (NNM)
• Launched: 18th December 2017 (officially rolled out 8th March 2018, International Women's Day, from Jhunjhunu, Rajasthan)
• Coverage: All 36 States/UTs
• Duration: Initially for 3 years commencing 2017-18 (later extended/upgraded to Poshan 2.0)
• Nodal Ministry: Ministry of Women and Child Development (MoWCD)
• Budget: Rs. 9046.17 crore (2017-20)

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Objective / Goal

• Children 0-6 years
• Adolescent girls
• Pregnant women
• Lactating mothers

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Targets (5 Fixed Targets)

Memory aid: Targets 1, 2, 5 = 6% total (2%/year); Targets 3, 4 = 9% total (3%/year)

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Approach: Life Cycle Approach

Pre-pregnancy / Adolescent girl
        ↓
Pregnant woman (especially first 1,000 days - conception to 2 years)
        ↓
Lactating mother / Newborn
        ↓
Child under 6 years (pre-school)
        ↓
School-age child / Adolescent

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Convergence of Programmes

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Key Features / Pillars

1. Technology-driven monitoring

• Poshan Tracker Application - real-time monitoring of >14 lakh Anganwadi Centres and ~9 crore beneficiaries
• Use of IT-based tools for tracking beneficiaries, monitoring growth, and accountability

2. Jan Andolan (People's Movement)

• Community mobilization and mass awareness on nutrition
• Poshan Maah (Nutrition Month) - celebrated every September with community-level activities
• Poshan Pakhwada (Nutrition Fortnight) - twice yearly nutritional awareness campaigns
• The Jan Andolan approach has generated over 150 crore activities nationwide

3. Convergence

• Convergence of services across multiple schemes and ministries (detailed above)
• Targets convergent actions at the AWC level

4. Incentive structure

• States/districts given incentives for achieving targets
• Incremental improvements rewarded

5. Behavioral Change Communication (BCC)

• Focused nutrition and health education
• Community-based activities involving families and frontline workers

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Additional Schemes Under ICDS / Poshan Abhiyan

(a) SABLA - Rajiv Gandhi Scheme for Empowerment of Adolescent Girls

• Target: Girls 11-18 years
• Aim: Improve nutritional and health status, self-development, literacy, vocational skills

(b) IGMSY - Indira Gandhi Matritva Sahyog Yojana

• Conditional cash transfer to pregnant and lactating mothers
• Aim: Improve nutritional and health status of mothers

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ICDS Status (2019 data from Park's)

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Poshan 2.0 (Mission POSHAN 2.0) - Updated

• Supplementary Nutrition Programme (SNP)
• POSHAN Abhiyan

• Mother and Child Nutrition
• Early stimulation for brain development
• Play-based education in early years
• Role of parents and community in minimizing screen time
• Strengthening the Anganwadi as a community hub
• Community-based management of acute malnutrition (CMAM) protocols

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Significance in PSM

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Key Numbers Summary for Exam

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Mid-Day Meal Scheme in PSM

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Introduction and Names

• It is one of the largest school feeding programmes in the world
• Reaches over 11 crore children in more than 11 lakh schools

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Objectives

Primary Objective (Park's):

Expanded Objectives (NP-NSPE/PM POSHAN):

1. Universalization of primary education by increasing:
   • Enrolment
   • Retention
   • Attendance
2. Simultaneously impacting on nutritional status of school children
3. Reorientation of eating habits
4. Incorporating nutrition education into the school curriculum
5. Encouraging use of local commodities
6. Improving educational performance of pupils

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Historical Milestones

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Coverage / Beneficiaries

• Originally: Classes I to V (primary stage) in government, local body and government-aided schools
• Extended to: Classes I to VIII (upper primary added later)
• PM POSHAN further extended to: Pre-primary (Bal Vatika) classes in government and government-aided schools

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Nutritional Norms

Original Scheme (Park's - for primary classes I-V):

MDM Rules 2015 (Updated norms):

Park's key principle: The meal should supply at least one-third of total energy requirement and half of protein need of the child.

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Model Menu (Park's - Table 39)

• The National Institute of Nutrition (NIN), Hyderabad has prepared model recipes suitable for both North and South Indians
• Minimum feeding days required: 250 days per year (to have desired impact)

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Principles of Formulating Mid-Day Meals (6 Principles - Park's)

1. (a) The meal should be a supplement and NOT a substitute to the home diet
2. (b) The meal should supply at least one-third of total energy requirement and half of protein need
3. (c) The cost of the meal should be reasonably low
4. (d) The meal should be easily prepared in schools; no complicated cooking process
5. (e) As far as possible, locally available foods should be used (reduces cost)
6. (f) The menu should be frequently changed to avoid monotony

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Suggestions for Nutritious and Economical Meals (Park's)

• Use whole wheat or broken wheat (dalia) for preparation
• Rice should preferably be parboiled or unpolished
• Single dish meals using broken wheat/rice + pulse + seasonal vegetable + edible oil - saves time and fuel (e.g., broken wheat pulao, leafy khicheri, upma, dal-vegetable bhaat)
• Cereal-pulse combination is necessary for good quality protein; cereal:pulse ratio = 3:1 to 5:1
• Use sprouted pulses - they have more nutrients
• Fermentation improves nutritive value - idli, dosa, dhokla should be encouraged
• Leafy vegetables should be washed before cutting, not after
• Soaking of rice/dal reduces cooking time; wash grains thoroughly
• Rice water should never be thrown away - mix with dal
• Cook with lid on to avoid nutrient loss
• Avoid overcooking
• Avoid reheating of oil used for frying
• Leafy tops of carrots, radish, turnips should be utilized, not discarded
• Only iodized salt should be used for cooking

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Funding Structure

• Central Government: Provides free food grain from nearest Food Corporation of India (FCI) godown + transport subsidy
• Cost sharing: Centre 60% : States 40%
• Central assistance for cooking cost, honorarium for cook-cum-helpers, infrastructure, etc.

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Important Goals of School Feeding Programme

1. Reorientation of eating habits of children
2. Incorporating nutrition education into the curriculum
3. Encouraging use of local commodities
4. Improving school attendance and educational performance
5. Since numbers to be fed are in millions - maintaining balance between resources and number to be fed

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PM POSHAN (2021 Update) - New Features

• New name: Pradhan Mantri Poshan Shakti Nirman (PM POSHAN)
• Approved for 5 years (2021-22 to 2025-26)
• Extended coverage to pre-primary (Bal Vatika) children in government schools
• Emphasis on nutritional quality and dietary diversity
• Convergence with Poshan Abhiyan / Mission Poshan 2.0
• Encourages inclusion of locally grown nutritious items like millets, eggs, fruits, and vegetables

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Benefits / Impact

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Key Numbers Summary for Exam

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ORS as an Example of Appropriate Technology in PSM

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Part 1: Appropriate Technology - Definition and Concept

Definition (Park's):

"Technology that is scientifically sound, adaptable to local needs, and acceptable to those who apply it and those for whom it is used, and that can be maintained by the people themselves in keeping with the principle of self-reliance with the resources the community and country can afford."

Why "Appropriate" Is Emphasized:

• In some countries, large, luxurious hospitals totally inappropriate to local needs are built, absorbing a major part of the national health budget, effectively blocking any improvement in general health services
• Similarly, costly equipment and procedures are used when cheaper, scientifically valid and acceptable alternatives are available
• The word "appropriate" distinguishes technology that truly serves the community's needs from technology that is expensive, complex, or inaccessible

Examples of Appropriate Technology (Park's):

1. Oral Rehydration Fluid (ORS) - for diarrhoea management (the classic example)
2. Standpipes for water supply - socially acceptable and financially more feasible than house-to-house connections

Context in Primary Health Care:

• Appropriate technology is one of the 8 essential components of Primary Health Care (Alma-Ata Declaration, 1978)
• It embodies the PHC philosophy of "Health by the People" - placing people's health in people's hands

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Part 2: ORS (Oral Rehydration Salts/Solution)

Why ORS is the Best Example of Appropriate Technology:

• Scientifically sound - based on proven glucose-sodium co-transport mechanism
• Adaptable to local needs - usable in any setting, from hospitals to homes
• Acceptable - easy to administer by mothers and community health workers
• Maintainable by the people themselves - can be prepared at home with simple ingredients
• Affordable - inexpensive ingredients, low cost
• Called a "major breakthrough" in the fight against cholera and diarrhoeal diseases

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Part 3: ORS - Full PSM Details

Background and Principle:

• Introduced by WHO; firmly established that ORT can be used for acute diarrhoeas of all aetiologies, in all age groups, and in all countries
• Aim: To prevent dehydration and reduce mortality
• Scientific basis: Glucose given orally enhances intestinal absorption of salt and water (glucose-sodium co-transport mechanism), and is capable of correcting the electrolyte and water deficit
• Experience from Kolkata: 90-95% of all cases of cholera and acute diarrhoea can be treated by oral fluids alone

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Evolution of ORS Composition:

Benefits of Reduced Osmolarity ORS over standard ORS:

• Unscheduled IV therapy need fell by 33%
• Stool output decreased by 20%
• Vomiting reduced by 30%
• As safe and effective as standard ORS for cholera too
• India was the FIRST country in the world to launch this formulation (since June 2004)
• Since January 2004 - the only formulation procured by UNICEF

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Composition of Reduced Osmolarity ORS (WHO/UNICEF - Current Standard):

In grams per litre:

In mmol per litre (electrolyte concentrations):

Compare: Standard/old ORS had osmolarity of 311 mOsm/L (Na 90 mmol/L); the reduced osmolarity version has 245 mOsm/L (Na 75 mmol/L)

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Home-Made ORS (Sugar-Salt Solution):

• 1 level teaspoon of table salt + 6 level teaspoons of sugar dissolved in 1 litre of drinking water
• Safe to use until proper ORS mixture is obtained
• Earlier the treatment is instituted, the better

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Assessment of Dehydration (Park's Table 3):

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Guidelines for ORT Administration (Park's Table 4 - First 4 hours):

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Practical Administration Rules (Park's):

• Children < 2 years: Give 1 teaspoon every 1-2 minutes; offer frequent sips from cup for older children
• Adults: May drink as much as they like
• After each loose stool:
  • Children < 2 years: 50-100 ml (¼ to ½ large cup)
  • Children 2-10 years: 100-200 ml (½ to 1 large cup)
  • Older children/adults: as much as they want
• If child vomits: Wait 10 minutes, then give slowly - 1 spoonful every 2-3 minutes
• Breastfeeding should be continued during ORS treatment
• Give as much as the child wants - if no vomiting and dehydration signs gone, rehydration complete
• ORS packet dissolved in 1 litre of drinking water
• Prepare fresh daily - use within 24 hours
• Do NOT boil or sterilize the solution

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Recommended Household Fluids (when ORS not available):

• Rice water (kanji)
• Unsalted soup
• Yoghurt drinks
• Green coconut water
• Weak tea
• Add 3 g salt/litre to unsalted drinks

• Commercial carbonated beverages (cause osmotic diarrhoea and hypernatraemia)
• Commercial fruit juices
• Sweetened tea
• Coffee
• Medicinal teas or infusions with stimulant/purgative/diuretic effects

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Feeding During Diarrhoea:

• Infant's usual diet of cereals, vegetables and other foods should be CONTINUED during diarrhoea
• Food should NEVER be withheld
• Child's usual food should NEVER be diluted
• Aim: Give as much nutrient-rich food as the child will accept
• Resume normal feeding as soon as possible

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Intravenous Rehydration (when ORS fails):

1. Ringer's Lactate (Hartmann's solution) - Best commercially available; supplies Na, K; lactate corrects acidosis
2. Diarrhoea Treatment Solution (DTS) - WHO recommended polyelectrolyte solution

• Normal saline: can be given if nothing else available (poorest option - does not correct acidosis or replace K)
• Plain glucose/dextrose: should NOT be used (provide only water and glucose)
• Recommended IV dose: 100 ml/kg

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Part 4: ORS as Appropriate Technology - Why It Qualifies

"The introduction of oral rehydration fluid has not only reduced the cost of treatment, but also made possible treatment of patients in their own homes by primary health workers or relatives of patient." - Park's PSM

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Key Numbers Summary for Exam

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BMI (Body Mass Index) in PSM

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Definition

---

Formula

Example (Park's):

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WHO Classification of Adults by BMI (Park's Table 2)

• BMI values are age-independent and the same for both sexes
• The WHO classification is based primarily on the association between BMI and mortality
• The risks associated with increasing BMI are continuous and graded and begin at a BMI above 25

Further subdivision of Underweight:

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Asian / Indian Cut-offs (Modified WHO)

• Indians tend to have higher body fat percentage at the same BMI compared to Caucasians
• This is related to the "thin-fat Indian" phenotype - relatively lean body but excess visceral/central fat

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BMI - Other Indices Used in Assessment of Obesity (Park's)

The BMI and Brocca index are most widely used. A FAO/WHO/UNU report gives reference tables for BMI usable internationally.

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Limitations of BMI (Park's)

1. Does NOT distinguish between weight associated with muscle and weight associated with fat
   • A muscular athlete may have a BMI ≥ 30 without excess fat
2. The relationship between BMI and body fat content varies by:
   • Body build and proportion
   • Ethnic group - Polynesians have lower fat % than Caucasians at identical BMI
   • Age - % body fat increases with age up to 60-65 years in both sexes
   • Sex - % body fat is higher in women than men of equivalent BMI
3. BMI values should be interpreted with caution in cross-sectional comparisons when estimating body fat
4. Not applicable directly to children (need age and sex-specific percentile charts)

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Other Methods of Assessing Obesity / Body Fat (Park's)

1. Body Weight

• Widely used but not accurate for excess fat
• Epidemiologically: +2 SD from median weight-for-height = cut-off for overweight; +3 SD = obesity

2. Skinfold Thickness

• Large proportion of total body fat is subcutaneous
• Measured with Harpenden Skin Callipers (non-invasive, rapid)
• Sites: Mid-triceps, biceps, subscapular, suprailiac (4 sites)
• Sum of measurements should be:
  • < 40 mm in boys
  • < 50 mm in girls
• Drawbacks: No universal standards for subcutaneous fat; impossible in extreme obesity; poor repeatability

3. Waist Circumference and Waist:Hip Ratio (WHR)

• Waist measured at midpoint between lower rib border and iliac crest
• Correlates closely with BMI and WHR
• Index of intra-abdominal (central) fat and total body fat
• Changes in waist circumference reflect changes in cardiovascular risk

Cut-offs for increased metabolic risk:

4. Advanced Methods (not for routine use):

• Total body water measurement
• Total body potassium measurement
• Body density measurement
• Fat cell measurement - opened new field in obesity research

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Intra-abdominal (Central) Fat and Health Risk (Park's)

• More cells per unit mass
• Higher blood flow
• More glucocorticoid (cortisol) receptors
• More androgen (testosterone) receptors
• Greater catecholamine-induced lipolysis
• Located upstream from the liver in the portal circulation → increased flux of non-esterified fatty acids to liver

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Hazards of Obesity (Park's)

(a) Increased Morbidity:

(b) Increased Mortality:

• Framingham Heart Study (USA): Dramatic increase in sudden death among men >20% overweight vs normal weight
• Increased mortality mainly due to: hypertension and CHD
• Excess deaths also from renal diseases
• Obesity lowers life expectancy

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BMI in PSM - Specific Applications

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BMI in Children and Adolescents

• Not applicable using adult cut-offs in children
• Uses age- and sex-specific percentile charts (CDC/WHO growth charts)
• At-risk for overweight: ≥ 85th percentile
• Overweight: ≥ 95th percentile
• Underweight: < 5th percentile

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Key Numbers Summary for Exam

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BMR (Basal Metabolic Rate) in PSM

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Definition

"Even when a person is at complete rest, considerable energy is required to perform all the chemical reactions of the body. This minimum level of energy required to exist is called the BMR." - Guyton & Hall

• Also called Resting Metabolic Rate (RMR) or Resting Energy Expenditure (REE) (RMR differs very little from BMR)
• Accounts for 50-70% of total daily energy expenditure in most sedentary persons

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Conditions for Measuring BMR (Standard Conditions)

1. The person must NOT have eaten food for at least 12 hours (post-absorptive state)
2. Determined after a night of restful sleep
3. No strenuous activity for at least 1 hour before the test
4. All psychic and physical factors causing excitement must be eliminated
5. Temperature of air must be comfortable - between 68°F and 80°F (20-26.7°C)
6. No physical activity permitted during the test
7. Person should be lying still and awake

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Normal Value of BMR

• Average BMR in a 70-kg adult man = 65-70 Calories (kcal) per hour
• Expressed as: kcal/hour/m² body surface area (to correct for body size differences)
• BMR is calculated from height and weight (surface area)

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Method of Measurement

Harris-Benedict Equation (Predictive formula):

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Factors Affecting BMR

Factors That INCREASE BMR:

Factors That DECREASE BMR:

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BMR and Age (Park's - ICMR 2020)

• Energy requirements decrease with age because of:
  1. Fall in BMR
  2. Decrease in physical activity

• After age 40: Reduce energy requirement by 5% per decade (up to age 60)
• After age 60: Reduce by 10% per decade
• Overall: 2% decline in resting metabolism per decade for adults

• High physical activity (almost equal to hard work in adults)
• Puberty: spurt in growth + increase in metabolic rate

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Components of Total Energy Expenditure (TEE)

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Key Related Terms (Park's)

Physical Activity Ratio (PAR):

• PAR is unitless
• Advantage: Can be used for both sexes, all ages, all body sizes (covariates appear in numerator and denominator and cancel out)

Physical Activity Level (PAL):

• Ratio of TEE to BMR over 24 hours
• Used to classify activity levels:
  • Sedentary: PAL 1.40-1.69
  • Moderate: PAL 1.70-1.99
  • Heavy: PAL ≥ 2.00

Total Energy Expenditure (TEE):

• TEE = BMR × PAL

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Caloric Values of Macronutrients (Park's)

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ICMR 2020 Daily Energy Requirements (Park's Table 23)

Adults:

Infants and Children:

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Key Numbers Summary for Exam

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