ANC - 1

13th Part

Q   Describe the objectives, target group, and the services provided under the following national nutrition programs:

(c)  National Prophylaxis Programme for Prevention of Nutritional Blindness  6  

A   Objectives: The main objective of the program is to prevent blindness due to vitamin A deficiency in children (between 6 months to 5 years) by supplying a mega (high) dose of vitamin A.

Target group: All children of 6 months to 5 years are eligible (particularly those living in rural, tribal, and urban slum areas).

Dose and distribution strategy: A liquid preparation of vitamin A in oil giving 200,000 IU (in 2 ml) is given to every child between the ages of 1 and 5 years. Vitamin A solution is kept away from direct sunlight and a bottle once opened is utilized within 6-8 weeks. A child must receive a total of 9 oral doses of vitamin A by the fifth birthday. An infant between the age of 6-11 months is given a dose of 100,000 IU. The contact with an infant is established during the administration of the measles vaccine between the age of 9-12 months. It is considered a practical time for administering the vitamin A supplement of 100,000 IU to infants. Distribution of vitamin A is carried out by the Auxiliary Nurse Midwife (ANM) - a functionary belonging to the Health Department in the Ministry of Health and Family Welfare

Q  Describe the objectives, target group, and the services provided under the following national nutrition programs:

(a) National Nutritional Anaemia Control Programme                    7

A  Objectives: The main aim of the program is to significantly decrease the cases of anaemia among women in the reproductive age group especially pregnant and lactating women and preschool children. The program focuses on the following :

# Promotion of regular consumption of foods rich in iron.

# To provide iron and folate supplements in the form of tablets to the "high risk" groups.

# Identification and treatment of severely anaemic cases.

Target group: The beneficiaries of the program are :

a) Pregnant women

b) Lactating mothers

c) Family planning acceptors (women who accept family planning measures like tubectomy)

d) Children of both-sexes between ages 1 to 5 years.

Distribution Strategy: Supply of iron-folic acid tablets to the target population. Two types of tablets being distributed are :

(1) big tablets, each containing 60 mg of iron (ferrous sulphate) & 500 Ug of folic acid (for women). One big tablet per day for 100 days should be given to a pregnant women after the first trimester. Similarly, lactating women and IUD acceptors should receive one tablet per day for 100 days. Mothers often accompany their infants on immunization sessions. They can be handed over tablets during this time.

(2) small tablets, each containing 20mg of iron and 100Ug of Folic acid for children daily for 100 days every year. For young children who cannot swallow tablets, iron and folk acid in 2 ml of syrupy liquid (in the same dose, as in a small tablet) should be given. Auxiliary Nurse Midwife (ANM) a functionary belonging to the Health Department in Ministry of Health and Family Welfare is responsible for the distribution of the tablets.

Q  What is the basis of the National Prophylaxis Programme for Prevention of Nutritional Blindness?

A  The basis of the program is the fact that the human liver can store large amounts of vitamin A. If large doses of vitamin A are given to preschool children, they can be stored and used whenever needed.

Q  State whether the following statements are true or false. Correct the false statements.

a)  Women of childbearing age and children are the target beneficiaries of the National Anaemia Control Programmes.

A  True

b)  Nutritional anaemia can be only due to iron and folic acid deficiency.

A  False; It can also be due to vitamin B12 deficiency

c)  Anaemia can even lead to the death of women during childbirth.

A  True

d)  Sixty milligrams of iron is given to women during pregnancy as a prophylactic measure.

A  True

e)  The dosage of iron and folic acid in the National Nutritional Anaemia Control Programme is the same for women and children.

A  No, Children are given smaller doses.

Q  Besides goitre other manifestations of iodine deficiency disorders include.................. and ................…

A    hypothyroidism, speech & hearing defects, muscular weakness, spasticity, stillbirth.

Q  National goitre control program was launched in the year ................ and is now known as ......................…

A  1962,  Iodine prophylaxis program

Q  Ten grams of iodized salt provides.. ..................... .micro, grams of iodine.

A  150

Q  Common salt is fortified with ..................... a compound of iodine.

A  potassium iodate

Q  List the main objectives of the Iodine Prophylaxis Programme.

A  The main objectives of the National IDD Control Programme are-

- to identify regions where IDD(goitre,cretinism) is rampant

- to supply iodized salt in endemic areas

- to assess the impact of the program over a period of time

Q  Why is salt chosen as the vehicle of supplying iodine in our country?

A  The main reasons are given below :

i) Salt is consumed by all communities of the country

ii) The consumption of salt is almost the same in all communities with minor variations.

iii) It is produced at few selected locations and hence its quality can be easily Monitored.

iv) The addition of iodine doesn’t change the appearance or taste.  

v) The technology to add iodine is not complicated or expensive.   

Q  Growth monitoring

Q  What is growth monitoring? Why is it useful to assess the nutritional status of children? 2+4

A  Growth Monitoring is a regular assessment of physical growth and measurement of the child through different ways (weight, length) which enables mothers to visualize growth or lack of it. Relevant and practical guidance thereafter can be obtained to ensure continued regular growth and health of children.

       The purpose of Growth Monitoring is to help identify the at-risk child, take action on the first sign of inadequate growth and integrate nutrition intervention (breastfeeding, supplementary feeding, etc.) with other health interventions (Immunization, ORT) to restore health and proper growth of children. Growth Monitoring is a preventive and promotive strategy aimed at the action before malnutrition occurs. 

Q  Complementary feeding practices

A.  Supplementary feeding means giving extra food to make up for the lack of energy and protein in a diet in order to prevent nutritional deficiencies among children. It is done by slowly substituting breast milk with solid and semi-solid foods. Breastfeeding is continued but the baby slowly gets accustomed to other foods along with breast milk so as to overcome the shortfall in the nutrients. This process of introducing foods other than breast milk in the diet of the infant is called supplementary feeding.

     In general, based on the age of the infant supplementary foods vary as follows:

(a) Liquid Supplements at - (4- 6 months)- it includes juices, soups or other milk substitutes (like animal milk)

(b) Semisolid to solid supplements(6 - 8 months) -well cooked and mashed, soft thin, liquid porridge made from the staple food of the community. The porridge can be prepared by cooking the cereals (i.e. wheat, rice, semolina, etc.) with milk and sugar.

(c) solid supplements( 8-12 months) - chopped vegetables like potato and carrots boiled and cut into small pieces. Minced meat and boiled fish could be served as such instead of mashing. Soft cooked rice or small pieces of chapaties may also be introduced at this stage.

6. a) Explain the principle of food preservation involved in the following: (1+1)

i.  Wax coating of Jam

A.  Certain micro-organisms require air for growth (aerobes) that ultimately leads to spoilage of food. Wax coating prevents air from coming in contact with the jam thus stopping the growth of aerobes. Hence by wax coating, we prevent jams from spoiling.

ii.  Blanching of vegetables before freezing.

A.  Natural enzymes lead to decay of vegetables. Blanching is a process in which we boil or steam vegetables briefly until they are partially cooked.  Blanching of vegetables before freezing destroys natural enzymes present in them and hence prevents self decomposition of food.

Q  List the different methods used for the assessment of nutritional status. Give the significance of anthropometric measurements in assessing nutritional status  (4)

A.  There are four major methods used to assess the nutritional status of individuals these are -

1. Anthropometric method - The anthropometric method refers to the measurements of body size. The four most commonly used body measurements which serve as good indicators of nutritional status are :

#  Weight for the age - Weight for age is a commonly used indicator of body size. It reflects the level of food intake. The relative change of weight with age is a more sensitive indicator of short duration malnutrition.

#  Height for age - Length or height is a very reliable measure. It reflects the total increase in the size of the individual up to the moment it is determined. For example, we know that normally a baby measures 50 cm at birth. This birth length increased to 75 cm at one year of age. By the age of four years, the child is 100 cm tall. Thereafter, the child gains about 5 cm in height every year, until the age of 10 years. Recording the height helps us to know whether the child is growing normally and if the health of the child is good or not.

#  Mid upper- Arm circumference for the age - The mid-upper arm circumference is an indicator of nutritional status of individuals and communities. Arm circumference normally increases with age, but between one to five years it does not change much and remains fairly constant. At this time the baby fat is replaced by muscle. Measuring the arm circumference of this age group helps us to know whether the child is in good health or not. The MUAC is, therefore, an easy and useful method of assessing the nutritional status of children in the age group 1-5 years. One can measure the roundness/fatness of a child's arm, using any ordinary measuring tape by placing it around the middle part of the child's left arm and recording the value. A measurement of less than 12.5 cm indicates severe malnutrition and a measure between 12.5 cm and 13.5 cm indicates moderate malnutrition.

#  Weight for height - Weight for height is a very good index for short duration malnutrition. This measurement is of value especially in situations where child health services are not available. Periodic monitoring is not available children are seen irregularly say once in a while.

2. Clinical method - Clinical examination is one of the simplest methods to assess nutritional status. It involves looking for changes (clinical signs/symptoms) in the body which are indicative of a particular deficiency. For example, bitot spots and night blindness in children suggest the possibility of vitamin A deficiency, paleness, lethargy in women suggest the possibility of anaemia.

3. Biochemical analysis - In this method, the body fluids (blood and urine normally) are analyzed to determine the nutritional status of individuals. For example. the level of Hb in the blood gives us an indication of iron content(or lack of it) in the body, a measure of the level of thiamine in the urine reflects the intake of thiamine in the diet, a measure of the level of vitamin A in the blood reflects intake and reserve of vitamin A in the body.

4. Diet survey - A systematic inquiry into the food supplies and food consumption of individuals and population groups is called diet survey. Dietary data can be collected covering a whole nation from families (of different economic classes) or from individuals of special age group or occupation depending on the need. There is a wide range of methods used in diet surveys like food frequency, diet history, 24-hour recall method, food record or diary, etc. The main purpose of the diet survey is -

# to collect information about food supplies and food consumption of individuals

and population groups.

# to find out inadequacies in the existing diet pattern.

{ The 24-hour recall: The 24-hour recall method is probably the most widely used method of dietary assessment. Under this method, the subject/individual is asked to Recall/describe, in as much detail as possible the food intake for the past 24 hours.

The individual recalls what was eaten, how much food was eaten, how was the food prepared, when was it eaten and other such details related to food intake.)

Significance of anthropometric measurements -  Anthropometric measures refer to the measurements of body size. Growth, as measured in terms of weight for age or height for age, reflects the sum total of what has occurred up to that point in time. Besides height and weight, measuring body circumference facilitates the identification of the degree of body fat and the number of lean body tissues i.e. muscles in the body. It aids in the identification of PEM and obesity.  

i.  Vitamin C plays an important role in wound healing

A.  Vitamin C plays an important role in wound healing because of the formation of a special kind of protein called collagen. The formation of collagen at the site of wound or injury aids in its healing. This protein is found in the connective tissue which holds together different other tissues much like cement holds bricks together. For example, collagen present in blood vessels makes them firm. The deficiency of vitamin C in the diet may result in fragile blood vessels which can easily rupture.

iv.  Colostrum is beneficial for infants

A.  Before milk is secreted colostrum is produced by the breast. Colostrum should be fed to the baby as it is good for growth and general well being. Colostrum is life-saving as it has protective functions. It contains a high concentration of antibodies and white blood cells which protects the child from infections.

iv)  Amylase rich food

A.  Amylase rich food is the flour obtained from germinated grain. Germinated grain flour contains a lot of amylases an enzyme that makes the porridge soft thin and easy to eat without taking away any of its nutritive value.

v)  Synergism    

A.  The interaction between two diseases resulting in increased complications or increased duration of the disease is called synergism. For example, if a child with moderate PEM also has infections like measles or diarrhoea, then due to synergism between these two diseases he may develop a severe form of kwashiorkor.

i)  Essential and non-essential amino acids

A.  Proteins are built up of just 22 amino acids. Of these, about 8 cannot be manufactured by the body while the rest can be manufactured. Those which cannot be manufactured by the body must be supplied by the diet. These amino acids are called essential amino acids. The amino acids which can be manufactured by the body are called non-essential amino acids.                                             

Essential Amino acids - Leucine, Lysine, Valine.

Non-Essential Amino acids - Cystine, Glycine, Proline.

iv)  Food laws and food standards

A.  Food laws - Food laws are extremely important for providing wholesome, nutritious, poison-free food to the public. Food laws encourage the production and handling of food under hygienic conditions and also prevent the chemical and microbiological contamination which are responsible for the outbreak of food-borne diseases and other health hazards affecting large segments of the population.

Food standards - It is considered as a specification or set of specifications that are to be met. Quality characteristics include those relating to general appearance, size, and shape, gloss, color, consistency, etc. We have two organizations that are empowered to lay down standards of quality for food items and to certify that these standards are met. These are the Bureau of Indian Standards (BIS) and the Directorate of Marketing and Inspection.

v)  IDDM and NIDDM

A.  Insulin-dependent diabetes mellitus (IDDM) - In this type of diabetes mellitus (in order to function normally) body is dependent on insulin doses from an exogenous source (outside source). It occurs more frequently in young children and adolescents.

Non-Insulin dependent diabetes mellitus (NIDDM) - In this type of diabetes mellitus there is a lack or insufficiency of insulin in the body which can be brought under control by either diet alone or a combination of diet and certain drugs. The body is not dependent on insulin from an outside source. This is frequently observed in adults (especially those who are overweight).

4.  Fill in the blanks

i) In dehydration, there is a loss of fluids and …………

A. Electrolytes

ii)  Bodyweight is less than ……..Kg is a risk factor during pregnancy

A. 8 Kg

iii)  The toxins present in Kesari dal affect the ………..system

A.  Nervous system

iv)  In the case of lactation failure …………milk is suitable for the babies.

A.  Cow milk

v) …………….present in green leafy vegetables and cereals interfere with absorption of calcium/phosphorus.

A.  (Phytates in cereals and) Oxalates in green leafy vegetables.

3.  List the deficiency and food sources of the following nutrients/substances: (5)

i) Thiamine

ii) Niacin

iii) Iodine

iv) Vitamin B12

v) Riboflavin

A. I) Thiamine or BI - is widely distributed in animal and plant foods. Plant foods such as whole-grain cereals (i.e. wheat and rice) and whole pulses are also rich sources of thiamine. Among the foods of animal origin lean meats, poultry, and egg yolk are good sources.

             Thiamine is a part of coenzymes that play a role in the metabolism of carbohydrates. Deficiency of thiamine in the diet can, therefore, interfere with carbohydrate metabolism.

Ii)  Niacin - Niacin is another member of the B-complex family. The good sources of niacin include meat, fish, poultry, cereals, pulses, nuts, and oilseeds. One interesting point about niacin is that it can also be formed in the body from an amino acid called tryptophan which is available in milk.

         Niacin (like riboflavin) is also part of coenzymes that help to release energy from the end products of the digestion of carbohydrates, fats, and proteins. It thus helps in their metabolism. The deficiency of Niacin could create problems in the digestion of carbohydrates, fats, and proteins.

Iii) Iodine - Crops such as vegetables especially those grown in coastal areas where iodine content of the soil is high have substantial amounts of iodine. Seafood like fish, shellfish are among the best sources of iodine.

             Iodine is a component of the hormone thyroxine secreted by the thyroid gland. Thyroxine regulates the rate of oxidation within the cells. If this regulation does not take place, both physical and mental growth will be affected. Iodine helps in the functioning of nerve and muscle tissues. The deficiency of iodine could lead to a disease called goitre.

Iv)  Vitamin B12 -  Vitamin B 12 or cobalamin is present only in the foods of animal origin. Liver, kidney, milk, eggs, and seafood (e.g. shrimps, crabs, lobsters) are rich sources of vitamin B 12.

         Vitamin Biz is necessary for the proper functioning of the digestive tract, nervous system, and bone marrow. In the bone marrow, vitamin B12 (like folic acid) is also involved in the formation of normal red blood cells. The deficiency of Vitamin B12 is thus extremely harmful to the proper functioning of the body.

v) Riboflavin - Riboflavin or B2 is widely distributed in plant and animal foods. Milk, liver, kidney, eggs, and green leafy vegetables are good sources of riboflavin. Whole grain cereals and pulses contain fair amounts.

          Riboflavin plays an important role in the metabolism of carbohydrates, fats, and proteins. This is because of the fact that it forms part of two distinct co-enzymes which help to release energy from the end products of digestion of carbohydrates, fats, and proteins. Its deficiency would lead to reduced metabolism of carbohydrates, fats, and proteins.