National control programme against nutritional blindness due to vitamin A deficiency: Current status & future strategy

Vitamin A deficiency (VAD) among 1-5 yr old children is reported to be widely prevalent in Southeast Asia and some parts of Africa. It is the leading cause of preventable blindness in young children in the low-income countries in the world. Children even with milder signs of VAD have higher risk of morbidity and mortality. Inadequate dietary intakes of vitamin A with poor bioavailability associated with frequent infections are the primary contributory factors. Currently available approaches to control VAD are ensuring adequate intakes of vitamin A in daily diets, fortification of foods consumed regularly particularly among the low-income communities and periodic administration of massive dose of vitamin A supported by public health interventions and reinforced by behaviour change communication. Under the National Programme in India, six monthly administration of mega dose of vitamin A to 6-59 month old children has been implemented since 1970, to prevent particularly blindness due to VAD and control hypovitaminosis A. Despite inadequate coverage and poor implementation of the programme, blindness due to VAD in children has almost disappeared, though subclinical VAD is still widely prevalent. Based on the results of meta-analysis of eight trials, which indicated that vitamin A supplementation to children aged 6-59 months reduced child mortality rates by about 23 per cent, the World Health Organization made a strong recommendation that in areas with VAD as a public health problem, vitamin A supplementation should be given to infants and children of 6-59 months of age as a public health intervention to reduce child morbidity and improve child survival. At present, in India, there is a need for change in policy with respect to the national programme to opt for targeted instead of universal distribution. However, NITI (National Institution for Transforming India) Aayog, which formulates policies and provides technical support to the Government of India, recommends strengthening of the National Programme for control of VAD through six monthly vitamin A supplementation along with health interventions. Eventually, the goal is to implement food based and horticulture-based interventions harmonizing with public health measures, food fortification and capacity building of functionaries for elimination of VAD.

Application of Factor Analysis to Identify Dietary Patterns and Use of Factor Scores to Study Their Relationship with Nutritional Status of Adult Rural Populations.

The prevalence of chronic energy deficiency (CED) among one-third of the Indian population is attributed to inadequacy of consumption of nutrients. However, considering the complexity of diets among Indians, the relationship between a particular dietary pattern and the nutritional status of the population has not been established so far. A community-based cross-sectional study was undertaken to assess estimates, at district level, of diet and nutritional status in Orissa State, India. Factor analysis was used for exploring the existence of consumption pattern of food and nutrients and their relationship with the nutritional status of rural adult population. Data on 2,864 adult men and 3,525 adult women in Orissa state revealed that there exists six patterns among food-groups explaining 59% of the total variation and three patterns among nutrients that explain 73% of the total variation among both adult men and women. The discriminant function analysis revealed that, overall, 53% of the men were correctly classified as either with chronic energy deficiency (CED) or without CED. Similarly, overall, 54% of the women were correctly classified as either with CED or without CED. The sensitivity of the model was 65% for both men and women, and the specificity was 46% and 41% respectively for men and women. In the case of classification of overweight/ obesity, the prediction of the model was about 75% among both men and women, along with high sensitivity. Using factor analysis, the dietary patterns were identified from the food and nutrient intake data. There exists a strong relationship between the dietary patterns and the nutritional status of rural adults. These results will help identify the community people with CED and help planners formulate nutritional interventions accordingly.

Efficacy and safety of cilostazol, a novel phosphodiesterase inhibitor in patients with intermittent claudication.

Pharmacotherapy is limited for the relief of intermittent claudication (IC), a common manifestation of peripheral arterial disease (PAD). Pentoxyfylline, the only current pharmacological therapy for IC, has been shown to have similar efficacy as placebo. Cilostazol, a new phosphodiesterase III (PDE III) inhibitor, is a potent inhibitor of platelet aggregation with vasodilatory, antithrombotic, antiproliferative and positive lipid-altering effects. To evaluate the efficacy and safety of cilostazol for the treatment of IC in Indian patients, 123 patients were selected from 6 centres in India. The patients, aged 58-73 years, with the diagnosis of stable moderate-to-severe IC received cilostazol 100/50 mg twice daily for a period of 12 weeks. Primary efficacy measures included initial claudication distance (ICD) and absolute walking distance (ACD) by treadmill testing and ankle-brachial index (ABI) using Doppler ultrasonography-measured systolic pressures. Secondary efficacy outcomes included subjective assessment of symptom improvement by patient and investigator and estimation of lipid values. Adverse events were monitored throughout the study. Laboratory investigations were carried out at baseline and end of study. At the end of week 12 of cilostazol therapy, there was a significant improvement in the raw walking distances (ICD and ACD). Percentage change in ICD and ACD was 46.77% and 64.5%, respectively, at the end of study. There was a significant increase (32.7%) in the ABI by the end of study period. According to patient and investigator assessment of symptoms, 58-60% of the subjects showed significant improvement to complete resolution of claudication symptoms by the end of 12 weeks of therapy. In addition, there was a significant increase of 20.24% in the mean plasma HDL-cholesterol levels and a decrease of 29.55% in the mean plasma triglyceride concentrations by the end of study period. Headache, diarrhoea, palpitation and dizziness were the commonly reported adverse effects during the study. No adverse effect led to discontinuation of therapy. The present study suggests that cilostazol is an effective therapeutic option with an acceptable tolerability profile for the treatment of IC in patients with PAD.

Diet and nutritional status of rural preschool children in Punjab.

OBJECTIVE: To assess diet and nutritional profile of rural preschool children of Punjab. STUDY DESIGN: Multistage random sampling method was adopted by following probability proportion to population size (PPS). SUBJECT: Four hundred households (HH) were covered in each district of Punjab for socio-economic and demographic information. All the available individuals from these HHs were included for anthropometry and clinical examination. Every fourth household was covered for 24-hour recall method of diet survey (individual dietary intake). RESULTS: At the state level, the intake of macro and micronutrient rich foods such as cereals, pulses and green leafy vegetables, milk and milk products and fats and oils were lower than the RDI among preschool children. Except for protein, calcium and thiamine, the mean intake of all the nutrients was lower than the recommended level. About a half of the preschool children (50.3%) were undernourished (> 2SD weight for age); 60% were stunted (> 2SD height for age) and 12% were wasted (> 2SD weight for height). The extent of undernutrition and stunting was lower than that reported for the country. There was significant variation in the prevalence of severe stunting between the districts (p < 0.001), with the highest being observed in the Rupnagar (55%) and the lowest in Hoshiarpur and Sangrur (30% each). CONCLUSION: Despite, the reported high rates of economic growth and food production in the state, a higher proportion of preschool children were consuming diets, which are inadequate with respect to energy, fat, iron, riboflavin, vitamin A and vitamin C. The prevalence of undernutrition was high as was found in other states.

Impact of mid day meal program on educational and nutritional status of school children in Karnataka.

OBJECTIVE: To assess the effect of the Mid Day Meal (MDM) Program on enrollment, attendance, dropout rate and retention rate in the schools and its impact on nutritional status as well as on school performance. DESIGN: Comparison by multistage random sampling. SUBJECTS: Primary school children, who are attending the school in the MDM and non-MDM areas. RESULTS: A total of 2,694 children (MDM: 1361; Non-MDM : 1333) from 60 schools were covered in the study. Results of the study indicated better enrollment (p<0.05) and attendance (p<0.001), higher retention rate with reduced dropout rate (p<0.001) a marginally higher scholastic performance and marginally higher growth performance of MDM children. CONCLUSION: MDM program is associated with a better educational and nutritional status of school children in Karnataka.

Diet & nutrition situation in rural India.

During the last 25 years, a large database has been accumulated on the diet and nutritional status of the rural population of different states of India. The National Nutrition Monitoring Bureau (NNMB) and the National Institute of Nutrition (NIN), Hyderabad have carried out extensive diet and nutrition surveys in 12 states of the country. These surveys indicate that the diets of the rural population are inadequate and deficient in most of the nutrients. There is widespread energy deficiency in the rural households. About 60 per cent of the preschool children are underweight (< median -2SD weight for age of NCHS) and 62 per cent are stunted (long duration malnutrition). About 15 per cent of the children of 1-5 yr of age suffer from short duration malnutrition (wasting). Repeat surveys showed that severe malnutrition had declined substantially in children. Similarly, there was reduction in the extent of chronic energy deficiency among the adults. However, there were no perceptible changes in the diet and nutrient intakes during the past 20 yr.

Impact evaluation of iron & iodine fortified salt.

As a novel approach to tackle the problems of iron deficiency anaemia and iodine deficiency disorders (IDDs), which often coexist, the National Institute of Nutrition has developed iron and iodine fortified common salt (double fortified salt-DFS) as a public health measure. This salt has undergone a battery of laboratory and field tests to evaluate its feasibility for use in a national programme. The DFS is designed to provide 1 mg of iron and 15 micrograms of iodine per gram of common salt. This was made possible by the inclusion of a polyphosphate stabilizer, sodium hexametaphosphate (SHMP) at 1 per cent level. The stability of iron and iodine was found to be good up to 6 months. However, the stability of iodine depended upon the quality of the salt used for fortification. The biological effects of long-term consumption of DFS were evaluated in experimental rats and in field trials. Both iron and iodine from the salt were found to be biologically available in regenerating haemoglobin and in increasing excretion of iodine in urine. When this salt was tested in tribal villages endemic for goitre and iron deficiency anaemia, the bioresponse was good with regard to the iodine status but was not uniform in all segments with regard to iron, probably due to confounding variables. In a study carried out in residential school children where such variables did not exist, DFS was found to have significant impact on haemoglobin status in anaemic children and improved their urinary iodine excretion. The consumption of DFS for 2 yr did not have any adverse effects in school children as well as in the tribal population. Parameters related to calcium homeostasis were not altered in children receiving DFS. Histopathological examination of tissues and radiological examination of bone did not reveal any abnormality in DFS fed rats. Similarly serum and urinary parameters related to calcium and phosphorus were not altered in DFS fed rats. Therefore, DFS is presented as a feasible and effective strategy to control the double deficiency of iron and iodine in our community.

Strategies for control of micronutrient malnutrition.

Micronutrient malnutrition, particularly vitamin A deficiency (VAD), iron deficiency anaemia (IDA) and iodine deficiency disorders (IDD), poses a serious threat to the health of vulnerable segments of population. Dietary Inadequacy is the primary cause of VAD and IDA, while poor iodine content of soil and water due to environmental iodine deficiency is the main determinant of IDD. Three major intervention strategies are available for the control of micronutrient malnutrition: supplementation of the specific micronutrients; fortification of foods with micronutrients; and horticulture intervention to increase production and nutrition education to ensure regular consumption of micronutrient rich foods. In India currently the national nutrition programmes being implemented for preventing these deficiencies are based on short term supplementation like periodic mega dosing of vitamin A, distribution of iron and folic acid tablets, and salt iodisation. Though these have been in operation for over two decades, there has been no perceptible biological impact on the prevalence of micronutrient malnutrition. Among the constraints, the most important are: lack of coordination, shortage of resources and manpower, inadequate and irregular supplies, lack of proper orientation and training to the functionaries, poor monitoring and supervision and absence of nutrition education. Integrated and multi-sectoral approaches are required to achieve the goals set under the National Nutrition Policy. These should include community-friendly nutrition education to increase awareness and motivation; active people's participation; food fortification; nutrient supplementation; nutrition oriented horticulture programmes; orientation of functionaries, and establishment of integrated micronutrient surveillance. Concerted and focussed efforts are needed to combat micronutrient malnutrition by the 2000 AD.

Evaluation of national nutritional anemia prophylaxis programme.

An evaluation of the National Nutritional Anemia Prophylaxis Program was carried out in Andhra Pradesh. About 8,000 respondents from about 5,754 households were interviewed and 487 pregnant women were covered for haemoglobin estimation in six selected districts. Nearly 19 per cent of the pregnant women had received folifer tablets, while about 1 per cent of child beneficiaries were receiving the tablets. The acceptance of the programme by the community appeared to be satisfactory. The reasons for poor coverage were reported to be inadequate and irregular supplies. Results indicated that the health functionaries were not properly oriented towards the programme, as many of them were not aware of all the beneficiaries under the programme. Chemical analysis of the tablets indicated that about 30 per cent of the tablet samples had iron content less than the expected levels, and none of them had expected levels of folic acid content.

Nutritional profile of preschool children of armed forces families around Hyderabad.

Three hundred and fifty three preschool children (1 to 5 years) belonging to armed forces families of non-officers (who often come from rural background) stationed at Military Station, Golconda, Hyderabad were studied for their clinical examination and anthropometric status. Diet survey by oral questionnaire was also carried out on a sub-sample of 48 children. The heights and weights of children from families of armed forces were far superior to those of rural Indian preschool children, but they were marginally shorter and lighter than those of well-to-do Hyderabad children. About 92% of the children had weights above 80% of Harvard median. The practical implication of these findings is that the children of rural families, with the usual socioeconomic constraints, when provided with steady income and comprehensive health care can be expected to achieve a growth status which is almost comparable to that of well-to-do children.