Nutrition Related Public Health Problems In Women

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Nutrition Related Public Health Problems In Women
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• Dual nutrition disease burden in women
• Under- nutrition
• Prevalence of under-nutrition and micronutrient
  deficiencies are high in adolescent girls,
  pregnant and lactating women
• Adverse consequences of macro and micronutrient
  under nutrition in women affect not only the
  mother but also her offspring
• Over-nutrition
• Data from NFHS and NNMB surveys indicate that
  over-nutrition in women is emerging as a public
  health problem especially in urban areas
• Over-nutrition is associated with increased risk
  of non-communicable diseases

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• This presentation will review
• Nutritionally vulnerable periods in womans life
• Effect of maternal under-nutrition on mother
  child dyad
• Anaemia and its adverse effects
• Magnitude of undernutrition in women

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Nutritionally vulnerable periods in womans life
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Effect of pregnancy on nutritional status

• Women from poor households subsist on
  16-1800kcal/day there is no increase in dietary
  intake during pregnancy.
• Mean weight gain during pregnancy is 5-7 kg.
  There is a reduction in FFT indicating that there
  is mobilisation of fat.

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• There is no increase in dietary intake during
  lactation.
• There is reduction in body weight and FFT during
  first year of lactation suggesting that there is
  mobilisation of fat to meet the energy needs.
  Body weight improves after 12 months

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Factors predisposing to maternal under-nutrition
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NFHS-2

• Many adolescent girls have not completed their
  physical growth
• If pregnancy occurs in early teens, there will be
  no further linear growth

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• Women who had severe/moderate undernutrition in
  childhood are shorter and lighter in adult life.
• Birthweight is lower in women who are short or
  having poor weight gain during pregnancy.

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Pregnancy in lactating women imposes additional
nutritional needs the impact is greater if
inter-pregnancy interval is short. If dietary
intake remains low, there is deterioration in
maternal nutritional status and poor maternal
weight gain
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WW-working women HW Housewife
Working at home and out side home imposes
additional energy needs if not met there is
reduction in bodyweight
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Effect of maternal nutrition on birth weight
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Maternal under-nutrition is associated with
increased risk of low birth weight.
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Mean birth weight is lower if IPI is less than
12 months. Mean birth weight in all groups is
lower if conception has occurred in lactating
women
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Poor pregnancy outcome in low income groups is
partly due undernutrition/ anaemia and partly
due to poor ANC.
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• To sum up
• Pregnancy and lactation impose additional
  nutritional demands they can be met through
  lifestyle adaptations in well nourished women
• Situations associated with deterioration in
  maternal nutrition and reproductive performance
  are
• Pregnancy in undernourished adolescent girls
• Pregnancy in young adolescent girls
• Pregnancy in lactating women
• Pregnancy within two years of last delivery
• Dual stress of work at and outside home

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Interventions to improve maternal nutrition All
pregnant and lactating women should be weighed
Pregnant women with bodyweight less than 45 kg
are identified and given 6 kg food grains
every month for the remaining period in
pregnancy Lactating women with bodyweight less
than 40 kg are identified and given 6 kg food
grains every month for the remaining period of
lactation upto one year
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• Steps to improve household Nutrition security
• Increase production and availability of cereals,
  pulses and vegetables
• Reduce post harvest losses by appropriate
  processing .
• Make vegetables available at affordable cost
  through out the year to urban and rural
  population
• More efficient targeting through TPDS
• Provide coarse grains, pulses and iodised salt
  to BPL families through TPDS
• Improve purchasing power by appropriate
  programmes including food for work programmes

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Anaemia and its adverse consequences
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• Prevalence of anaemia Source WHO
•   Global Developed Developing
  India
• 
  Urban Rural
• Childrenlt5 yrs 43 12 51
  60 70
• Children gt 5yrs 37 7 46
  50 60
• Men 18 3 26 35
  45
• Women 35 11 47 50
  60
• Pregnant 59 14 51
  65 75
• Women
• About one third of the global population (over 2
  billion persons) are anaemic.
• Anaemia is the most common nutritional deficiency
  disorder in the world.
• Prevalence of anaemia is higher in developing
  countries
• Prevalence of anaemia in India is very high in
  all groups of the population.

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Prevalence of anaemia is high in South Asia. Even
among South Asian countries prevalence of anaemia
in pregnancy is highest in India.
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Source NNMB 2003
Among the southern states, prevalence of anaemia
in pregnancy is lower in Kerala and Tamil Nadu -
? due to better access to health care.
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Indias share in global maternal deaths
INDIA
It is estimated that globally there are over 5
lakh maternal deaths every year. There are about
1 to 1.2 lakh maternal deaths in India every
year. India with 16 global population accounts
for 20-25 of all maternal deaths in the world.
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Anaemia continues to be a major cause of maternal
deaths
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Source NNMB

• Majority of children, adolescents, adult men
  women are anaemic.
• Anaemia antedates pregnancy gets aggravated
  during pregnancy. Maternal anaemia results in
  poor iron stores in foetus.
• Prevalence of anaemia in children is high because
  of poor iron stores, low iron content of breast
  milk and complementary foods.
• There is thus an intergenerational
  self-perpetuating vicious cycle of anaemia in all
  age groups.

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Anaemia is a major problem right from childhood
it worsens during adolescence in girls Advent
of pregnancy further aggravates anaemia
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Anaemia in pregnant women (Age between 15 - 44
years)
Over the last five decades there has not been any
reduction in prevalence of anaemia even in
2003 (DLHS) over 90 of pregnant women are
anaemic
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Prevalence of anaemia is high even in high
income groups and among well educated pregnant
women.
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Time trends in intake of iron, folic acid and
vitamin C in rural and urban areas (c/day)
(NNMB)
Nutrients NNMB NNMB NNMB NNMB NNMB NNMB NNMB
Nutrients Rural Rural Rural Rural Rural Urban Urban
Nutrients 1975-79 1988-90 1996-97 2000-01 2004-05 1975-79 1993-94
Iron (mg) 30.2 28.4 24.9 17.5 14.8 24.9 18.96
Vit C 37 37 40 51 44 40 42
Folic acid 153 62 52.3
Dietary intake of iron and folate are less than
50 of RDA. Bioavailability of iron from phytate
and fibre rich Indian diets is only 3 -5.
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Time trends in intake of iron (mg / day) in different groups Time trends in intake of iron (mg / day) in different groups Time trends in intake of iron (mg / day) in different groups Time trends in intake of iron (mg / day) in different groups Time trends in intake of iron (mg / day) in different groups Time trends in intake of iron (mg / day) in different groups
Age group Age group 1975-79 1996-97 2000-01 2004-05
10-12 B 19 20 12.2 12
10-12 G 18 19 12.1 11.5
13-15 B 21 21 15.4 13.3
13-15 G 20 21 12.9 13
16-17 B 25 26 16.7 16.4
16-17 G 22 22 15.3 13.4
Adult men 26 27 17.5 19.6
Adult women 21 22 17.1 13.8
Pregnant 20 23 14 14
Lactating 23 23 14.6 14.7
Iron intake is low in all age groups and does not
increase in pregnancy there has been no increase
in iron intake over 3 decades.
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Prevalence of Iron deficiency anemia in South Asia Prevalence of Iron deficiency anemia in South Asia Prevalence of Iron deficiency anemia in South Asia Prevalence of Iron deficiency anemia in South Asia Prevalence of Iron deficiency anemia in South Asia
Country Children lt 5 years Women 15-49 years Pregnant women Maternal deaths from anemia
Afghanistan 65 61 - -
Bangladesh 55 36 74 2600
Bhutan 81 55 68 lt100
India 75 51 87 22000
Nepal 65 62 63 760
South Asia Region Total 25,560
World Total 50,000
About half the deaths from anaemia in the world
occur in South Asian countries. India accounts
for over 80 of deaths due to anaemia in South
Asia.
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• Consequences of anaemia in pregnancy
• 8-11 g/dL easy fatigability, poor work capacity
• 5-7.9 g/dL impaired immune function, increased
  morbidity due to infections
• lt5 g/dL compensated stage increased morbidity
  and maternal mortality due to inability to
  withstand even small amount of bleeding during
  pregnancy /delivery and increased risk of
  infections
• lt5 g/dL decompensated stage about 1/3rd develop
  severe congestive cardiac failure and many with
  congestive failure succumb either during
  pregnancy or during labour
• There is 8 to 10 fold increase in ? MMR when the
  Hb is lt5 g.

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Effect of maternal hemoglobin level on birth weight and perinatal mortality ( Prema 1982) Effect of maternal hemoglobin level on birth weight and perinatal mortality ( Prema 1982) Effect of maternal hemoglobin level on birth weight and perinatal mortality ( Prema 1982) Effect of maternal hemoglobin level on birth weight and perinatal mortality ( Prema 1982) Effect of maternal hemoglobin level on birth weight and perinatal mortality ( Prema 1982)
Effects on Hemoglobin (g/dL) Hemoglobin (g/dL) Hemoglobin (g/dL) Hemoglobin (g/dL)
lt5 5-7.9 8-10.9 11.0
Mean birth weight(g) 2,400 2,530 2,660 2,710
Perinatal mortality (rate/1000 live births) 500 174 76 55
Number 312 362 1015 1456

• Maternal anaemia is associated with poor
  intrauterine growth and increased risk of preterm
  births resulting in increase low birth weight
  rates.
• This in turn results in higher perinatal
  morbidity and mortality, higher IMR and poor
  growth trajectory in infancy, childhood and
  adolescence.
• A doubling of low birth weight rate and 2 to 3
  fold increase in the perinatal mortality rates is
  seen when the Hb is lt8 g.

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• Immune status of anaemic pregnant women
• There is a fall in T and B cell count when
  maternal Hb is below 11g/dL.
• The fall in T and B cell counts are significant
  when Hb is lt8g/dL.
• There is no alterations in lymphocyte
  transformation or in cell mediated immunity.
• Prevalence of morbidity due to infections
  including asymptomatic bacteriuria is higher in
  anaemic pregnant women.
• Higher morbidity rates might contribute to the
  higher low birth-weight rates in anaemic pregnant
  women.

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Interventions to prevent/ treat anaemia
Counseling to improve dietary diversity/ double
fortified salt if available Screen all pregnant
women as early in pregnancy as possible If not
anaemic IFA tablets through out pregnancy to
prevent anaemia If anaemic oral or IM iron
depending upon the severity of anaemia and
period of pregnancy
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• Programmes for prevention and management of
  anaemia in pregnancy
• India was the first developing country to take
  up a National Nutritional Anaemia Prophylaxis
  Programme to prevent anaemia among pregnant women
  and children in 1973.
• At that time AN care coverage under rural
  primary health care was very low and there was no
  provision for screening pregnant women for
  anaemia. Therefore an attempt was made to
  identify all pregnant women and give them 100
  tablets containing 60mg of iron 500µg of folic
  acid.
• In hospital settings, screening for anaemia and
  iron-folate therapy in appropriate doses and
  route of administration for the prevention and
  management of anaemia have been incorporated as
  an essential component of antenatal care.

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• Management of anaemia in pregnancy
• Obstetric text books in India provided country
  specific protocols for management of anaemia,
  based on studies carried out in the country.
• Hb lt 5 g/dL
• Constitute 5- 10 of anaemic women,
• Admission and intensive care preferably in
  secondary or tertiary care institutions to ensure
  maternal and fetal salvage.
• Hb 5 to 7.9g/dL
• Constitute 10 to 20 of anaemic women,
• Screen for systemic/obstetric problems and
  infections,
• If she has no other systemic or obstetric
  problems give her parenteral iron (IV or IM).

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• Total Dose IV Iron (TDI) therapy
• Safety and efficacy of Intravenous total dose
  iron therapy was proved by trials undertaken by
  Dr Menon.
• Subsequently IV total dose iron therapy was used
  in several hospitals in Chennai and elsewhere.
• Advantage Only two day hospital admission
• Disadvantage On rare occasions anaphylactic
  reaction occurred even in the tertiary care
  hospitals it was not possible to save all women
  who had anaphylactic reaction.
• In view of this TDI was given up and
  intramuscular iron therapy was preferred.

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IM iron therapy IRON DEXTRAN - Following initial
successful trials by Dr. Menon, Dr. Bhatt and
others, IM iron dextran injections were widely
used in hospital settings often on out-patient
basis about 1/3rd develop fever arthralgia or
myalgia. IRON SORBITOL COMPLEX Initial trials by
Dr. Menon showed promising results but it was not
so widely used because 1/3rd of the drug gets
excreted in urine and higher dose of elemental
iron is required. Side effects are mild nausea,
giddiness.
Effect of IM iron dextran on Hb birth weight (Prema 1982) Effect of IM iron dextran on Hb birth weight (Prema 1982) Effect of IM iron dextran on Hb birth weight (Prema 1982)
Group No. No.
Hb lt 8g/dl untreated 443 2530 651
IM iron from 20 weeks 76 2890 428
IM iron from 28 weeks 105 2734 416
None of the women who received 1gm of IM iron dextran had Hb less than 11g/dl at delivery. None of the women who received 1gm of IM iron dextran had Hb less than 11g/dl at delivery. None of the women who received 1gm of IM iron dextran had Hb less than 11g/dl at delivery.
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Problems in implementation of anaemia prevention
and control programmes
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DLHS 1 (1998-99) showed that pregnant women were
not being screened for anaemia and given
appropriate therapy. All pregnant women who were
given antenatal check up were given tablets
containing iron (100mg) and folic acid 500
µg. Most women in poorly performing states did
not come for antenatal check up. Many of those
who came, did not get IFA through out pregnancy.
Majority did not consume even the tablets that
they got.
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• Proportion of pregnant women who receive IFA
  tablets is not high even among well-performing
  states like Tamil Nadu, Kerala and Maharashtra.
• Many of those who received IFA did not receive
  100 tablets.
• Many of those who received did not take the
  tablets regularly.

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Hb in Pregnant women taking Iron Supplementation (ICMR 2000) Hb in Pregnant women taking Iron Supplementation (ICMR 2000) Hb in Pregnant women taking Iron Supplementation (ICMR 2000) Hb in Pregnant women taking Iron Supplementation (ICMR 2000)
No of tablets ingested No. Hb (g/dL) Hb (g/dL)
No. Mean S.D
1-15 310 8.8 1.7
16-30 251 9.2 1.5
31-60 196 9.3 1.8
61-90 99 9.2 1.6
gt90 74 9.1 2.1
Total who had IFA 930 9.1 2.2
B.Not known 16 9.1 2.6
C.Not had IFA 3829 9.1 3.8
ABC 4775 9.1 3.5
ICMR study confirmed that most women received 90
tablets without Hb screening. Many did not take
tablets regularly. Even among small number of
women who took over 90 tablets rise in Hb was low
and many continued to be anaemic.
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• IM iron therapy
• IM iron therapy mainly iron dextran was used in
  some medical colleges and rarely at district
  hospitals. It never reached primary health care
  level.
• There were problems in ensuring continuous supply
  of drugs even at medical colleges.
• Some women found it difficult to come to OPD
  daily for ten days for IM injections.
• Though women who were counseled agreed to IM
  therapy, those who developed trouble some side
  effects like arthralgia wanted to discontinue
  convincing them to continue was difficult.

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New initiatives in the Tenth Plan NRHM
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New Initiatives in the Tenth Plan Emphasis on
screening all pregnant women for anaemia
providing appropriate treatment depending upon Hb
levels. Anaemia prophylaxis For women who are not
anaemic one tablet of iron 100mg 500 µg folic
acid once a day would be sufficient to prevent
any deterioration in Hb levels. Oral iron therapy
for mild anaemia Majority of anaemic pregnant
women have mild anaemia. Oral iron folate therapy
(one tablet of iron 100mg and 500 µg twice a day)
regularly should be able to improve their Hb. IM
iron therapy for moderate anaemia One-fifth of
pregnant women have moderate anaemia. They should
get IM iron therapy. Hospitalisation and
intensive care for those with severe anaemia.

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Components of antenatal care DLHS -2
DLHS 2 (2006) showed that there was some
improvement in coverage and content of antenatal
care. About 40 women had blood examination
which might include Hb estimation.
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Iron Folic Acid Supplementation in
pregnancy DLHS 2
During Entire Pregnancy
IFA Per Day
DLHS 2 also showed that there has been some
improvement in of pregnant women receiving IFA
tablets. There has been a significant reduction
in the of women who received but did not
consume the tablets. These data suggest that if
all pregnant women are screened for anaemia and
provided appropriate therapy it might be possible
to achieve substantial reduction in prevalence of
anaemia in pregnancy.
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Challenges in the Eleventh Plan period
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• Challenges in anaemia prevention control
  programmes
• Majority of Indians are anaemic,
• Over 3/4th of pregnant women are anaemic,
• There has not been any decline in the prevalence
  of anaemia or its adverse consequences on mother
  child dyad over the last six decades.

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Opportunities in the Eleventh Plan period
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• Strategy for prevention of anaemia in pregnancy
• health and nutrition education to improve over
  all dietary intakes and promote consumption of
  iron and folate-rich foodstuffs - possible
  through NRHMs Health and Nutrition Days,
• dietary diversification and inclusion of iron
  folate rich foods as well as food items that
  promote iron absorption - possible with proper
  linkages with National Horticultural Mission,
• introduction of iron and iodine-fortified salt
  universally to improve iron intake - possible
  with NIN technology,
• Opportunity
• Affordable sustainable interventions to improve
  iron and folate intake of the entire family and
  prevent anaemia are readily available.

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• Strategy for prevention of anaemia in pregnancy
• focus on Hb estimation for detection and
  treatment of anemia in adolescent school girls as
  a part of school health check possible through
  school health system.
• focus on Hb estimation in girls/women who are
  married, for detection and treatment of anemia
  prior to pregnancy - can be attempted through
  coordination with AWW.
• screening all pregnant women for anemia -
  Possible using filter paper blood collection for
  Hb estimation by cyanmethaemoglobin technique
• providing one tablet of IFA to prevent any fall
  in Hb levels in non-anaemic pregnant women -
  possible through NRHM.
• Opportunity
• All these interventions are feasible affordable
  for the individual and health system. With
  universal coverage and monitored supplementation
  it is possible to ensure that non-anaemic women
  do not become anaemic.

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• Strategy for detection management of anaemia
• in pregnancy
• Diagnosis of anaemia by a gold standard time
  tested method of estimating Hb eg
  cyanmethaemoglobin possible by upgrading
  equipment in hospitals and urban health
  facilities
• iron folate oral medication at the maximum
  tolerable dose throughout pregnancy for women
  with Hb between 8 10.9g/dL possible through
  convergence between AWW and ANM,
• IM iron therapy for women with Hb between 5 and
  7.9 g/dL if they do not have any obstetric or
  systemic complication - possible with urban
  rural PHCs taking the major responsibility,

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• hospital admission and intensive personalised
  care for women with haemoglobin less than 5 g/dl
  - possible with referral to tertiary care centres
  using emergency transport funds and ASHA,
• screening and effective management of obstetric
  and systemic problems in anaemic pregnant women -
  possible in hospitals,
• improvement in health education to the community
  to promote utilisation of available care -
  possible through AWW, ASHA, ANM and local self
  government representatives.
• Opportunity
• All these interventions are feasible affordable
  for the individual and health system.

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Opportunities for prevention, detection and
appropriate management of anemia in pregnant
women Delhi currently has the necessary
infrastructure, manpower, technology and funds
for this task Indians are rational and
responsive peoples institutions are in place
for providing the necessary community
support Prevention, detection and appropriate
management of anemia in pregnant women and
preventing the adverse consequences of anaemia on
the mother child dyad is feasible under NRHM and
its urban counterpart. Delhi should take this
opportunity to showcase how it can cope with a
major challenge effectively.
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Time trends in dietary intake and nutritional
status
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• Over years there has been decline in cereal and
  pulse intake some increase in fat intake
• Over all energy intake has declined both in urban
  and rural areas micronutrient intake is low
• Inspite of increase in fat intake fat supplies
  less than 15 of energy

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Time trends in mean heights in rural /urban women
Source NNMB Reports
Increase in height over three decades is less
than 4 cms children and women are shorter as
compared to NCHS norms
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Time trends in mean weights in rural and urban
women
Source NNMB Reports
Increment in weight over three decades is higher
than increment in height . Urban women weigh
more than the rural women even though their
height is similar
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Time trends in mean triceps fatfold thickness in
rural urban women
Source NNMB Reports

• Over years there has been an increase in fat fold
  thickness in all age groups increase in fat fold
  thickness is more in urban women
• The increment in body weight in women is mainly
  due to increment in fat

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• Over the last three decades there has been a
  slow but steady decline in undernutrition both in
  women and men
• Since mid nineties there has been a some
  increase in overnutrition rates even in rural
  women .
• In 2005 prevalence of both under and over
  nutrition in women are higher than men

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• Even among poorer segments of population, there
  is a progressive reduction in under-nutrition and
  progressive increase in over-nutrition with
  increasing age

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• Prevalence of overnutrition is higher among women
  belonging to urban areas and from families with
  high income

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• There are huge interstate differences in
  prevalence of both under and over-nutrition
• By and large states with low under-nutrition
  rates had high over-nutrition and vice versa
• In most states with high over-nutrition rates
  have high longevity they may face high NCD risk
  

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Changes in body weight in HIG
Source Wasuda and Siddhu

• Even in women from high income group, the energy
  intake is less than ICMR RDA.
• Energy expenditure is lower than intake by about
  75- 100Kcal
• This positive energy balance leads to a
  progressive increase in body weight over decades

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Health consequences of over-nutrition
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Prevalence of diabetes and impaired glucose
tolerance in women is high especially in urban
areas
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Over decades there has been a steep increase in
hypertension, especially in urban
areas Prevalence rates in women are as high as in
men
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Coronary heart disease is more common in urban
men and women IHD is as common in women as in men
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Summary and conclusions Over the last three
decades there has been a decline in household
expenditure on food, cereal and energy
intake. Unlike the earlier era poverty and poor
access to food are not the major determinants of
low dietary intake Nutrition education and better
utilization of health and nutrition care can
result in rapid improvement in dietary intake and
nutritional status
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Under-nutrition in infancy, childhood and
adolescence predisposes to under-nutrition and
over nutrition in adult life Prevalence of
maternal under-nutrition is high especially in
states/areas where access to nutrition and health
care is low Maternal under-nutrition is
associated with higher morbidity due to
infections. Infections aggravate undernutrition
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Over decades there has been no decline in
anaemia Anaemia is present from infancy and
childhood gets aggravated during adolescence in
girls and is perpetuated by pregnancy Anaemia is
responsible for substantial increase in maternal
morbidity mortality Maternal under-nutrition
and anaemia are major factors responsible for low
birth weight
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Inspite of reduction in energy intake there has
been an increase in over-nutrition Reduction in
physical activity is the major factor responsible
for emerging problem of over nutrition Over-nutrit
ion predisposes to diabetes, hypertension and
CHD In India prevalence of diabetes,
hypertension, CHD is high prevalence rates in
women are comparable to those in men Effective
behavioral change communication promoting healthy
life styles will enable India to combat
over-nutrition and its adverse consequences
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Thank You