Study Material

UNIT 4: Public Health and Nutrition Disorders

Chapter 1: Major Deficiency Disorder: (PEM in the

context of underweight, stunting, wasting, SAM;
Nutritional Anemia with special reference to Iron
Deficiency Anemia; Vitamin A Deficiency
(Xeropthalmia); Iodine deficiency Disorders; Zinc
Deficiency; Prevalence, causes, consequences and its
control.

Chapter 2: Other Nutrition Problems: Vitamin B

complex deficiencies, Vitamin-C deficiency, Vitamin D
Deficiency.

Chapter 3: overweight/obesity:
Definition/classification (WHO), causes and
consequences.

Chapter 4: Non Communicable Diseases (Diabetes,

CVD, cancer) concept, prevalence, causes (Behavioral)
and consequences.

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 CHAPTER 1
In this chapter we will study about Public health nutrition (PHN). It is defined
as the science and art of preventing disease, prolonging life and promoting
health through the medium of nutrition. The aim is to achieve greater health
and well-being for everyone by making healthier food and nutrition-related
choices. Thus, the focus is on the promotion of good health through nutrition
and the primary prevention of nutrition related illness in the population like
protein energy malnutrition and other nutritional deficiency diseases and
disorders.

Protein Energy Malnutrition (PEM)

You must have read in daily newspapers that child malnutrition is a major health
problem in India and globally, leading to morbidity and mortality, impaired
intellectual development and working capacity, and increased risk of adult
disease. Protein Energy Malnutrition (PEM) occurs in three clinical forms, viz.
kwashiorkor, marasmus and marasrnic-kwashiorkor. In addition, a large number
of children suffer from various sub-clinical forms of PEM like underweight (low
weight for age), stunting (short stature or low height for age) 'and wasting
(thinness). In fact, the proportion of clinical cases of PEM in a given community
reflects only the-proverbial "tip of iceberg". In

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other words, for every clinical case there are many more children
suffering from underweight, stunting and wasting.
The World Health Organization (WHO) defines malnutrition as "the cellular
imbalance between the supply of nutrients and energy and the body's demand for
them to ensure growth, maintenance, and specific functions."
Malnutrition in children: Child growth is internationally recognized as an
important indicator of nutritional status and health in populations.
Now we will learn about the various sub clinical form of malnutrition that is:

Wasting: Wasting refers to low weight-for-height and the child is thin for his/her
height but not necessarily short. It is also known as acute malnutrition.
Wasting in children is a symptom of acute under nutrition, usually as a
consequence of insufficient food intake or a high incidence of infectious
diseases, especially diarrhea.

Stunting: Stunted growth refers to low height-for-age, when a child is short for
his/her age but not necessarily thin. It is also known as chronic malnutrition,
and carries long-term developmental risks. Stunting is the impaired growth and
development that children experience from poor nutrition, repeated infection,
and inadequate psychosocial stimulation.

Under-weight: Under-weight refers to low weight-for-age, when a child can be

either thin or short for his/her age. This reflects a combination of chronic and
acute malnutrition.

Stunting and Under-weight children are most likely to suffer from impaired
development and are more vulnerable to disease and illness.

Mothers should monitor their babies' growth from birth by taking them monthly
to the local clinic where they will be weighed and have

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their growth plotted on a chart. This should ensure that correct
information and advice are provided to mothers support the
appropriate growth of their babies.

Box: Three standard indices of physical growth that describe the

nutritional status
for children under five years of age: Wasting;
stunting and underweight.

Indicator What it measure/What it is

used for

Low weight- WASTING

for-height (acute
malnutrition)

Low height- STUNTING

for-age or (chronic
Low length- malnutrition)
for- age

Low weight-
for-age UNDERWEIGHT
(acute or chronic
malnutrition, or both)

The Fig: given below provides a snapshot of malnutrition in

children compared with a normal child.

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Fig- Malnutrition in children

Severe Acute Malnutrition (SAM)

Malnutrition is a major health concern in Indian children, not only in rural

areas, but in urban slums too. Now we will study about it. Severe Acute
Malnutrition (SAM) is the most extreme and visible form of under nutrition.
Its face is a child – frail and skeletal-who requires urgent treatment to survive.
WHO and UNICEF define Severe Acute Malnutrition (SAM) for children
aged 6 months to 60 months as:
• very low weight for the height
• visible severe muscles loss
• mid upper arm circumference (MUAC) below 115mm/ 11.5 cm (Fig)
• nutritional edema; and characterized by swollen feet, face and limbs

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Fig: Measuring Mid upper arrn circumference (MUAC) in

children.
MAM: Moderate acute malnutrition, SAM: Severe acute
malnutrition

Fig ; Mid arm circumference measuring tape for children 6-59 months

Severe Acute Malnutrition (SAM) is a major cause of death in children

under 5, and its prevention and treatment are critical to child survival a
development.
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Fig: Checking for edema (swelling in feet)

Management of Severe Acute Malnutrition (SAM)

The Ministry of Women and Child Development in India has been running
the Integrated Child Development Services (ICDS) since 1975 to address
child malnutrition. ICDS tracks the underweight or weight-for-age status of
children up to 6 years of age through a network of informal preschools
called Anganwadi centers. Each center is staffed with a community-based
worker and helper who provide nutritional supplementation to children and
pregnant women, basic informal education to children and health education
to mothers.

Nutritional management of SAM usually includes two types of

nutritional formulas termed as F-75 and F-100 formulas. These formulas are
made by preparing a mixture of milk, sugar, cereal and vegetable oil in
specified amounts. These formulas are given to SAM patients under strict
medical supervision. F-75 formula is given in the starting stage and
contains 75 kcal of energy and
0.9 g protein per 100ml. F-100 formula is given in a later stage and contains
100 kcal of energy and 2.9g proteins per 100ml.

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IRON DEFICIENCY ANEMIA

Anemia is a condition in which a person lacks sufficient healthy hemoglobin,

the substance carrying oxygen in red blood cells. This disease is very common,
and can result in the person feeling tired, weak, dizzy, and short of breath.
Nutritional deficiency anemia mainly results from a lack of iron, but a lack of
folic acid, vitamin- B12 and vitamin- A can also cause anemia, and a low
vitamin C intake can contribute.
Nutritional deficiency anemia can happen because of a lack of nutrients in the
diet or because of an illness or medical condition that make it hard to absorb
nutrients.
Population groups at high risk of anemia are infants and under 5 children,
school age children (6-14 yrs), adolescent girls (10 to 19 yrs) and women of
child bearing age (15-44 yrs).
Fig describes intergenerational cycle of anemia in women. According to
Intergenerational cycle of Anemia - An adolescent girl who enters the
reproductive age with low iron stores and becomes pregnant during
adolescence or later is at greater risk of giving birth to a low birth weight and
preterm baby. The baby is also born with low iron stores and due to poor infant
feeding practices is more likely than ever to enter adolescence with low iron
stores in the body. Thus this vicious cycle of iron deficiency anemia continues.

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Adolescent
enters
reproductive
age group
with low iron
stores
Adolescent
with low iron
and Pregnant
hemoglobin women with
levels + anemia
Menstrural
blood loss

Baby with
Uncorrected
low iron
anemia in
and
infancy and
hemoglobin
childhood
levels

Fig- Intergenerational cycle of anemia in women.

Prevalence - According to the National Family Health Survey 4 (NFHS-4)

of India, conducted in 2015/16, anemia prevalence across all ages is extremely
high in India; varying from 30 percent to 69 percent.

Causes
A few major causes of iron deficiency anemia are given
below:
• Increased iron demand during pregnancy.
• Daily diet poor in iron rich foods and other essential nutrients
(VitaminB12, Folic Acid) required for hemoglobin synthesis.
• Diets low in “iron enhancers” (citrus fruits, sprouts etc.) and excess of
“iron inhibitors” (tea, coffee, phytates, calcium rich foods etc.).
• Worm infestation (Hookworm)
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Menstrual blood losses.

Consequences
Iron deficiency anemia leads to following consequences:
• Reduced physical development- Chronic fatigue decreased work output
and decreased work capacity.
• Impaired sexual and reproductive development- Irregular menstruation,
low pre-pregnancy iron stores and low birth weight babies and pre-term
delivery.
• Reduced cognitive development-Diminished concentration, disturbance
in perception and poor learning ability.

Food Sources of Dietary Iron

Dietary iron is available in two forms: heme iron, found in animal muscle
and blood, and non-heme iron, found both in animal products and plant
foods. (Fig :)

SOURCES OF IRON

Heme iron Non Heme iron

Live Leafy
r vegetable
Meat Legumes
Poul Bean
try s
fish Cere
als

Fig : Food sources of Heme and Non-heme iron

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Healthful sources of iron include greens and legumes. Although the myth
persists that meat is a preferred iron source, a balanced vegetarian diet
containing legumes, fortified or whole grains, and green vegetables easily
provides adequate iron. (Fig )

• Fruits and vegetables aid the absorption of nonheme iron. Fruits and
vegetables contain vitamin C and organic acids (e.g., citric acid) that keep iron
in a reduced form, increasing absorption of nonheme iron when consumed in
the same meal.
• Tea, coffee, and cocoa should not be consumed with meals if poor iron
status is suspected. Polyphenols in these beverages inhibit the absorption of
nonheme iron. Black tea appears to be the most strong in this regard.

Fig: Dietary sources of iron

National Programs for Iron deficiency Anemia Control

• National Iron Plus Initiative in 2013 –Supplementation throughout life

cycle bi-weekly iron supplementation for preschool children 6 months
to 5 years, children from 1st to 5th grade in schools ,school children (5–
10 years) ,adolescents (10–19 years) pregnant, lactating women and
women in reproductive age.

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• Intensified National Iron Plus Initiative (I-NIPI) - The reduction of
anemia is one of the important objectives of the POSHAN Abhiyaan
launched in March 2018. Complying with the targets of POSHAN
Abhiyaan and National Nutrition Strategy set by NITI Aayog, the
Anemia Mukt Bharat strategy has been designed to reduce prevalence
of anemia by 3 percentage points per year among children, adolescents
and women in the reproductive age group (15–49 years), between the
year 2018 and 2022 by the Ministry of Health and Family Welfare
Government of India.
The National Iron+ Initiative will reach the following age groups for
supplementation or preventive programming:
•Bi-weekly iron supplementation for preschool children 6 months to 5 years
• Weekly supplementation for children from 1st to 5th grade in Govt. & Govt.
Aided schools •Weekly supplementation for out of school children (5–10
years) at Anganwadi Centres
•Weekly supplementation for adolescents (10–19 years)
•Pregnant and lactating women
• Weekly supplementation for women in reproductive age

Management of Iron Deficiency Anemia (IDA)

Iron deficiency anemia may be prevented or corrected by following methods:
Nutrition education-The education of the people to promote dietary
intake of iron rich foods is the foremost requirement for alleviating the
problem of iron deficiency anemia in all age groups.
Dietary diversification is encouraging the consumption of micronutrient
rich foods – dark green leafy vegetables, lentils and vitamin C rich fruits –
which may be available but are under-

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utilized by the deficient population.
Food fortification refers to the addition of micronutrients to processed
foods. In many situations, this strategy can lead to relatively rapid
improvements in the micronutrient status of a population, and at a very
reasonable cost, especially if advantage can be taken of existing technology
and local distribution networks.
Supplementation are highly concentrated vitamins and minerals produced
by pharmaceutical manufacturers in the form of capsules, tablets or
injections and administered as part of health care or specific nutrition
campaigns.

VITAMIN –A DEFICIENCY (VAD)

In this chapter we will learn about vitamin A. It is a fat soluble vitamin

required for vision, repair, reproduction and growth. This occurs in two
forms, as retinol in animal based food i.e. meat liver, fish, egg-yolk, milk,
cheese, butter and ghee and as beta- carotene in plant based food i.e. green
leafy vegetables, yellow fruits and vegetables like mango ,papaya,
pumpkin and carrots. (Fig)
Carotene is converted into retinol in the intestine, which is then absorbed
and stored in the liver.
Prevalence The current prevalence of subclinical vitamin A
deficiency among children below 6 years of age in India is 57% and
clinical is 0.7%.

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Fig : Food sources of Vitamin A

Causes

A few major causes of vitamin A deficiency are:

• Prolonged dietary deprivation-in endemic areas such as southern and
eastern Asia, where rice devoid of beta-carotene is the staple food.
• Breast milk of a lactating mother with vitamin A deficiency contains little
vitamin A ,which provides a breast-fed child with too little vitamin A.
• Decreased bioavailability of provitamin A carotenoids.
• Interference with absorption, storage, or transport of vitamin A.

Consequences
The consequences of vitamin A deficiency can be described as given
below:
• VAD leads to ocular manifestation that included under the term
“xerophthalmia” (xerosis=dryness; dry eye) night blindness, conjunctival
xerosis, bitot’s spots, corneal xerosis, corneal ulcer, keratomalcia are the
stages of ocular manifestation.
• VAD can impair growth, weaken the immune system and thus

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• Higher risk of respiratory infection and diarrhea.

• Pregnant women having serum retinol level <20 μg/dl (<0.70 μmol/l),
which is indicative of VAD, during the third trimester of pregnancy are at
a higher risk of preterm delivery and maternal anemia.

Vitamin A deficiency Control- Vitamin A is an important

micronutrient for maintaining normal growth, maintaining visual and
reproductive function. Diet surveys have shown that the intake of
vitamin A is significantly lower than the recommended daily
allowances in young children, adolescent girls and pregnant women.
National prophylaxis programme against Nutritional blindness was
initiated as centrally sponsored scheme was launched in 1970. In the
fifties and sixties many states reported that blindness due to Vitamin A
deficiency was one of the major causes of blindness in children below
1-5 years.
Aim of the programme is to decrease the prevalence of vitamin A
deficiency.
The objectives of the programme are:
• Prevention of vitamin A deficiency
a) Promoting consumption of vitamin A rich foods.
b) Creating awareness about the importance of preventing vitamin
A deficiency.
c) Prophylactic vitamin A as per the following dosage schedule:
▪ 100000IU at 9 months with measles immunization
▪ 200000 IU at 16-18 months, with DPT booster
▪ 200000 IU every 6 months, up to the age of 5 years Thus, a
total of 9 mega doses are to be given from
9 months of age up to 5 years

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• Treatment of vitamin A deficient children
a) All children with xerophthalmia are to be treated at health
facilities.
b) All children having measles, to be given 1 dose of vitamin A if
they have not received it is in the previous months.
c) All cases of severe malnutrition to be given on additional dose
of vitamin A.

Community base Prevention Strategies

• Nutrition education-The education of the people to promote
dietary intake of vitamin A and B – carotene rich foods is the
foremost requirement for alleviating the problem of vitamin A
deficiency in all age groups.
• Horticultural interventions including home gardening-
Ensuring an adequate supply of carotene rich foods for the
population is one of the most important prerequisites for promoting
the dietary intake of vitamin A.
• Prevention of infection-Vitamin A deficiency is often precipitated
by infections including measles, diarrhea and acute respiratory
infection.
• Selective fortification-The first food fortified with vitamin A in
India was vanaspati. All hydrogenated fats, by legislation are
expected to be fortified with vitamins A and D. Selective
fortification of food with vitamin A is recommended.
Food Safety and Standards Authority of India (FSSAI) has notified
the Food Fortification Regulations, 2018, while food business
operators (FBOs) need to comply with the provisions of these
regulations by January 1, [Link] new

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standards now provide a minimum and maximum range for
fortification of staples like wheat flour (atta), maida, rice, salt,
vegetable oil and milk, while the dosage of the micronutrients has
been adjusted to provide 30 to 50 per cent of the daily requirements.
In milk and oil, the unit of dosage has been changed to microgram
Retinol Equivalent for Vitamin A and microgram for Vitamin D from
IU. In wheat flour and rice fortification, other sources of iron have
been added, while vanaspati fortification has been excluded.

IODINE DEFICIENCY DISORDER (IDD)

Iodine is a trace mineral required for optimal mental and physical

development and is a key constituent of thyroid hormones. It is required
daily in very minute quantities (100 –
150 micrograms) for normal human growth and mental development.
Iodine deficiency is the single largest cause of preventable brain damage
globally. Iodine deficiency disorders (IDDs) include goitre, cretinism,
hypothyroidism, abortion, stillbirth, brain damage, learning disabilities,
mental retardation, psychomotor defects, hearing and speech impairment.
Prevalence- Iodine deficiency disorders (IDDs) constitute a significant
public health problem globally. In India, the entire population is prone to
IDDs due to deficiency of iodine in the soil of the sub-continent and thus
both animal and plant source food grown on the iodine-deficient soil.
Causes - The causes of IDDs are indirectly attributed to low iodine
content in the soil and hence in the consumed food, inadequate
utilization due to presence of goitrogens (glucan) in food like
cabbage,cauliflower and millets.
Consequences Severe iodine deficiency is related with

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various adverse effects, including goiter, cretinism, neonatal
hypothyroidism, growth retardation, and increased risks of pregnancy loss
and infant mortality. Supplementation of iodine through salt in the form
of iodised salt in the diet has proved cost effective in controlling and
eliminating IDD.

Fig- Iodine Deficiency Disorders; Goitre and Cretinism

Iodine deficiency disorder Control –National Iodine Deficiency Disorders

Control Programme (NIDDCP)
Realizing the magnitude of the problem, the Government of India launched a
100 per cent centrally assisted National Goitre Control Programme (NGCP) in
1962. In August, 1992 the National Goitre Control Programme (NGCP) was
renamed as National Iodine Deficiency Disorders Control Programme
(NIDDCP) with a view of wide spectrum of Iodine Deficiency Disorders like
mental and physical retardation, deaf mutisim, cretinism, still births, abortions
etc. The goal of the programme is
• To bring the prevalence of IDD to below 5% in the country.
• To ensure 100% consumption of adequately iodated salt (15ppm) at the
household level.

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ZINC DEFICIENCY

Zinc is a mineral. It is called an "essential trace element" because very small

amounts of zinc are necessary for human health. Since the human body does not
store excess zinc, it must be consumed regularly as part of the diet. Zinc performs
many factions as a part of every cell in the body and so zinc is essential for
normal growth, development, reproduction, and immunity. Zinc is present in
all cells, tissues, organs fluids and secretion although about 90% body’s zinc
is in muscles and bone.
Prevalence- In India mild to moderate deficiency of zinc may be widely
prevalent due to cereal pulse based diets, low in zinc and high in phytates that
may cause zinc deficiency. Phytate, or phytic acid, is a naturally occurring
compound found in all plant foods like beans, grains, nuts, and seeds. The
chief concern about phytates is that they can bind to certain dietary minerals
including iron, zinc, manganese and, to a lesser extent calcium, and slow their
absorption. Phytates in your everyday meals should not be an issue for you as
long as you’re eating a balanced diet. Though all age groups of the population
are at risk of zinc deficiency but infants and young children, pregnant and
lactating women are the most vulnerable.
Causes A few causes of zinc deficiency are
• Inadequate dietary intake-low zinc diet, protein energy deficiency,
vegetarianism,
patients on low or protein restricted diet.
• Malabsorption - celiac disease, pancreatic insufficiency
• Increased body losses –starvation, burns, choric blood loss,
excessive sweating, parasitic infection, sickle cell anemia

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Consequences The consequences of zinc deficiency may be
following as listed below:
• Poor maternal zinc status has been associated with fetal loss, birth
deformities in child, intrauterine growth retardation, low birth weight,
Growth retardation, prolonged labor and preterm or post-term
deliveries.
• Immune dysfunction and infection
• Skin lesions
• Decreased wound healing
• Sickle cell anemia
• Neurological diseases
• Infertility
• Liver disease

Zinc deficiency control – Home based methods of preventing zinc

deficiency are modifying eating habits and cooking practices. Adoption of
cooking practices like fermentation for making idli, dhokla etc , soaking
and germination of pulses and grains reduces the phytate content.
Likewise, a simple intervention such as taking a piece of guava or Indian
gooseberry (amla) fruit after food or while taking iron tablets would
double the availability of iron and zinc in the body.

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CHAPTER 2

Acquire knowledge of their dietary sources and management strategies.

Vitamins are mainly grouped into two categories: fat soluble and water soluble.
In this unit we will study about water-soluble vitamins, which include all of
the B vitamins and vitamin C. These vitamins are easily absorbed into the
body. If you consume more of a water-soluble vitamin than you need, the
excess will be excreted, not stored. This means the risk of an overdose is low,
but you have to constantly refill your stock. We will also study about an
important fat-soluble vitamin, vitamin D, which requires bile acids to help
absorb them, but your body keeps stocks of the excess for ready use.

VITAMIN-B COMPLEX

Vitamin B complex is composed of eight water-soluble

vitamins:

1. Thiamine
2. Riboflavin
3. Niacin
4. pantothenic acid
5. Pyridoxine

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6. Biotin
7. Folic acid
8. Cobalamin

Vitamins B- complex play a vital role in maintaining good health and

well-being. As the building blocks of a healthy body, B vitamins have a
direct impact on your energy levels, brain function, and cell metabolism.

Table: Summary of vitamin functions, deficiency and its sources

Functions Deficiency Sources

Vitamin

Thiamin Normal growth , Beriberi (deficiency Liver, whole or

(Vitamin coenzyme in disease); enriched grains,
B1) carbohydrate gastrointestinal: loss legumes, wheat
metabolism and of appetite, gastric germ
normal function of distress, indigestion,
heart, nerves and deficient hydrochloric
muscle acid; central nervous
system: fatigue, nerve
damage, paralysis;
cardiovascular: heart
failure, edema
of the legs

Riboflavin Normal growth and Ariboflavinosis; Milk, meats,

(Vitamin
energy and coenzyme wound aggravation enriched cereals,

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B2) in protein and energy cracks at the corners green vegetables
metabolism of the mouth, a
swollen red tongue,
eye irritation and
skin
eruptions

Niacin Coenzyme in energy Pellagra (deficiency Fortified cereals

(Vitamin production and normal disease), weakness, and grains
B3) growth loss of appetite,
diarrhea, scaly
dermatitis, neuritis
andconfusion

Pantotheni Formation of Unlikely because of Meats, eggs, milk,

c acid coenzyme A; fat, widespread whole grains,
(Vitamin cholesterol, protein, distribution in most legumes,
B5) and heme formation foods vegetables

Pyridoxine Coenzyme in amino acid Anemia, Wheat germ,

(Vitamin metabolism: protein hyperirritability, legumes, meats,
B6) synthesis, heme convulsions and poultry, seafood
formation, brain activity, neuritis
carrier for
amino acid absorption

Biotin Coenzyme A partner; Hair loss (alopecia) Liver, egg yolk,

(Vitamin synthesis of fatty acids, and a scaly red rash soy flour, nuts
B7) amino acids, around the eyes,
and purines nose and mouth

Folic acid Coenzyme in DNA Megaloblastic Liver, green leafy

(Vitamin and RNA synthesis; anemia (large vegetables,
B9) red blood cells immature red blood legumes, yeast,
maturation cells), poor growth, fortified orange
neural tube defects juice

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Cyanocoba Coenzyme in synthesis Pernicious anemia; Liver, lean meats,
lam of heme for poor nerve function fish, seafood
(vitamin haemoglobin; myelin
B12) sheath formation to
protect nerves

Fig: Foods rich in B complex vitamins

VITAMIN-C

Vitamin C is a water-soluble vitamin. It can be synthesized by many

mammals, but not by humans. The highest vitamin C content is found
in green and red peppers, broccoli, citrus fruits, strawberries, melons,
tomatoes, raw cabbage, potatoes, and leafy greens such as spinach,
turnip, and mustard greens. Meat, fish, poultry, eggs, and dairy
products contain much smaller amounts, and cereal grains contain
essentially none. Losses of vitamin C occur when foods are cooked
in large amounts of water, exposed to extensive heating, or exposed
to air.

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Fig: Vitamin C rich foods

Dietary deficiency of vitamin C may lead to Scurvy with

following symptoms (Fig):

Fig: Symptoms of vitamin C deficiency (scurvy)

Bleeding and swelling of gums, Joint pain, particularly in legs, Weakness or

fatigue, Weakness or fatigue and swelling on wounds.

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 VITAMIN D

Vitamin D is necessary for various body functions. Vitamin D is a fat-soluble

vitamin that our body produces when the skin gets exposed to sunlight.
The major source of Vitamin D is the endogenous synthesis in skin on
exposure to sunlight, namely, ultraviolet B (UV-B) radiation of wavelength
290–320 nm. Main dietary sources are fish, fortified

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food, and supplements. Vegetables and grains are poor sources. (Fig)
Synthesis of vitamin in skin on exposure to UV-B is also affected by latitude,
solar zenith angle, atmospheric pollution, ozone layer, and melanin
pigmentation.
Prevalence The prevalence of Vitamin D deficiency is reported worldwide,
both in sunshine deficient and sunshine sufficient countries. Still, it is the most
underdiagnosed and undertreated nutritional deficiency in the world.

Fig: Vitamin D rich Foods

Causes: Vitamin D deficiency is quite extensive in India. Apart from little
intake in diet, people with liver, kidney and skin disorders also have Vitamin
D deficiency. There are many reasons for it being so common in our country.
• Increased indoor lifestyle, thereby preventing sufficient exposure to
sunlight. This is mainly in the urban population due to modernization.
• Pollution can slow down the synthesis of Vitamin D in the skin by UV rays
• Changing food habits add to low dietary calcium and Vitamin D intake

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• Phytates and phosphates which are there in fiber rich diet, can
lessen Vitamin D stores and increase calcium requirement
• Increased skin pigmentation and application of sunscreens
• Cultural practices such as the burqa and purdah system
Consequences: The commonly known consequences of Vitamin D deficiency
are rickets in children and osteomalacia and osteoporosis in adults. In children, it
causes defective mineralization of bone due to imbalance between calcium and
phosphorous in the bone, resulting in rickets and external skeletal deformity. It
also causes muscle weakness and bone pain. In adults, inadequate dietary intake
of Vitamin D leads to poor absorption of calcium from diet and increased
calcium resorption from the bone and kidney and reduces bone mineral density
resulting in osteoporosis and osteomalacia, muscle weakness and increased risk
of falls.
Even though we are attentive of the causes of Vitamin D deficiency, we are not
able to prevent it to a great extent. India being a tropical country has adequate
sunshine. Most of the Indian population live in areas with adequate sunlight
throughout the year and are expected to have adequate Vitamin D. Contrary to
this, the prevalence of Vitamin D deficiency is high in India.
This is due to the skin complexion, poor exposure to sunlight, sunscreen creams,
Indian dietary habits and lower intake of Vitamin D fortified foods
Vitamin D and sun exposure It is advised to have sun exposure between 11.00 am
and 2.00 pm for maximum vitamin D production in our body.
The table summarizes the function , deficiency and sources of vitamins we have
studied so far.

Table: Summary of vitamin functions, deficiency and its sources

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Functions Deficiency Sources
Vitamin

Ascorbic Antioxidant;,collagen Scurvy (deficiency Citrus fruits, kiwi,

acid synthesis, helps prepare disease), sore gums, tomatoes, melons,
(Vitamin iron for absorption and hemorrhages, strawberries, dark
C) release to tissues for red especially around leafy vegetables,
blood cell formation and bones and joints, chili peppers,
metabolism anemia, tendency to cabbage, broccoli,
bruise easily, impaired chard, green and red
wound healing and peppers, and
tissue formation and potatoes
weakened bones

Cholecalcif Absorption of calcium Rickets and growth Synthesized in the

erol and phosphorus, retardation in skin with exposure
(Vitamin calcification of bones and children, to sunlight, fortified
D) teeth and growth osteomalacia (soft milk, fish oils
bones) in adults

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CHAPTER 3

In this chapter you will learn why is maintaining a healthy weight

important reaching to prevent and control many diseases and conditions. If
you are overweight or obese, you are at higher risk of developing serious
health problems, including heart disease, high blood pressure, diabetes,
breathing problems, and certain cancers. That is why maintaining a healthy
weight is so important: It helps you lower your risk for developing these
problems, helps you feel good about yourself, and gives you more energy to
enjoy life.
Body mass index (BMI) is a useful measure of overweight and obesity.
BMI is an estimate of body fat and a good gauge of your risk for diseases that
can occur with more body fat. The BMI is defined as the body mass (weight)
divided by the square of the body height, and is universally expressed in
units of kg/m2, resulting from mass in kilograms and height in meters. The
World Health Organization (WHO) regard a BMI of less than 18.5 as
underweight and a BMI of 25 or more as overweight and a person with a BMI
of 30 or more is generally considered obese.

BMI Formula: weight (kg) / [height (m)] 2

With the metric system, the formula for BMI is weight in kilograms divided
by height in meters squared. Since height is commonly measured in
centimeters, divide height in centimeters by 100 to obtain height in meters.
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Example: Weight=63kg, Height=160 cm (1.60m)
Calculation: 63 ÷ (1.60 x 1.60) = 24.60 kg/m2 this BMI IS in
normal category which is 18.5- 25.5
WHO classification of BMI

Classification BMI Kg/m2

Underweight <18.50
Severe <16.00
thinness
Moderate 16.00-16.99
thinness
Mild 17.00-18.49
Normal 18.50-24.99
range
Overweight ≥25.00
Pre-obese 25.00-29.99
Obese ≥30.00
Obese class I 30.00-34.99
Obese class 35.00-39.99
II
Obese class ≥40.00
III
Source: Adapted from WHO 1995, 2000 and 2004.

Causes of obesity

The fundamental cause of obesity and overweight is an energy

imbalance between calories consumed and calories expended.

Maintain energy balance-. The amount of energy or calories you get from
food and drinks (energy IN) is balanced with the energy your body uses for
things like breathing, digesting, and being physically active (energy OUT):
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• The same amount of energy IN and energy OUT over time =
weight stays the same (energy balance)
• More energy IN than OUT over time = weight gain
• More energy OUT than IN over time = weight loss

Fig: Energy balance

Lack of physical activity and exercise is second important factor related to
obesity. Many people have jobs that involve sitting at a desk most of the day.
They also rely on their cars rather than walking, or cycling.
Following are the other factors causes of obesity-

• Socio economic status

• Obesogenic environment
• Genetics factors
• Insufficient sleep
• Endocrine factors
• Medication
• Stress
• Smoking and alcohol

Changes in dietary and physical activity patterns are often the result of
environmental and societal changes associated with development and lack of
supportive policies in sectors such as health, agriculture, transport, urban
planning, environment, food processing, distribution, marketing, and
education.
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Consequences of overweight or obese

People who are overweight or obese, compared to those with a normal or

healthy weight, are at higher risk for many serious diseases and health
conditions, including the following-

A. Health Effects

• Diabetes
• Heart disease
• High blood pressure
• Osteoarthritis (a breakdown of cartilage and bone within a joint)
• Breathing problems
• Some cancers (colon, kidney, gallbladder, breast, and liver)

B. Psychological effects
• Mental illness such as clinical depression, anxiety, social
isolation and other mental disorders
• Negative self-image

C. Difficulties in day-to-day living

• Normal tasks become harder when you are obese, as movement is more
difficult
• You tend to tire more quickly and you find yourself short of breath
• Public transport seats, telephone booths, and cars may be too small for
you
• You may find it difficult to maintain personal hygiene
• Low quality of life

Currently in India, childhood obesity is also one of the most serious public
health challenges of the 21st century, particularly in urban settings.
Overweight and obese children are likely to stay obese into adulthood and
more likely to develop non-communicable diseases like diabetes and
cardiovascular diseases at a younger age.
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Overweight and obesity, as well as their related diseases, are
largely preventable. Prevention of childhood obesity therefore needs high
priority.
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CHAPTER 4

NON COMMUNICABLE DISEASES (NCDs)

In this chapter you will learn about non communicable diseases (NCD). The
term indicates that they that these disease cannot be transmitted from one
person to another. NCDs are also known as chronic diseases, as they tend to be
of long duration and are the result of a combination of genetic, physiological,
environmental and behavior factors. The main types of NCDs we will be
studying in this chapter are diabetes, cardiovascular diseases and cancer. Let us
now begin with Diabetes.

DIABETES MELLITUS

You must have seen a member in your family or any known person not eating
sugar or sugary foods saying that I am having sugar problem. This is medically
termed as Diabetes mellitus. It is a syndrome with disordered metabolism and
inappropriate high blood glucose level .When high blood glucose levels are
observed in blood in a women during pregnancy it is termed as gestational
diabetes. It is a diabetes that develops in a few women during pregnancy.
Diabetes is a chronic disease that occurs when the pancreas is no longer able
to m
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Insulin is a hormone made by the pancreas that acts like a key to
let glucose from the food we eat pass from the blood stream into the cells in
the body to produce energy. All carbohydrate foods are broken down into
glucose in the blood. Insulin helps glucose get into the cells.
Not being able to produce insulin or use it effectively leads to raised glucose
levels in the blood (known as hyperglycemia). Over the long-term high
glucose levels are associated with damage to the body and failure of various
organs and tissues.

Types of diabetes
Thus, there are three main types of diabetes – type 1, type 2 and
gestational diabetes.

• Type 1 diabetes can arise at any age, but occurs most commonly in
children and adolescents. When you have type 1 diabetes, your body
produces very less or no insulin, which means that you need daily
insulin injections to keep blood glucose levels under control.
• Type 2 diabetes is more frequently observed in adults and accounts
for approximately 90% of all diabetes cases. When you have type 2
diabetes, your body makes poor use of the insulin that it produces.
The basis of type 2 diabetes treatment is healthy lifestyle, including
increased physical activity and healthy diet. However, over time most
people with type 2 diabetes will require oral drugs and/or insulin to
keep their blood glucose levels under control.
• Gestational diabetes (GDM) is a type of diabetes that consists of
high blood glucose during pregnancy and is linked with
complications to both mother and child. GDM usually disappears
after pregnancy but women affected and their children are at
increased risk of developing type 2 diabetes later on in life.
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Prevalence
Unfavorable modifications of lifestyle and dietary habits associated with
urbanization are considered to be the most important factors for the steep
rise in its prevalence. Asians have vulnerability to diabetes when subjected
to unfavorable lifestyle. In the last one decade India has shown considerable
increase in the rate of prevalence both in urban and rural population.

Causes of diabetes mellitus

• Unhealthy eating
• Increasing age
• Heredity
• Overweight and Obesity
• Sedentary lifestyle
• Stress
• Smoking

Consequences of diabetes mellitus

Diabetes makes your blood sugar higher than normal. After many years,
too much sugar in the blood can cause problems in your body. It can
harm eyes, kidneys, nerves, skin, heart, and blood vessels.

Diabetes Management
A diabetes diet simply means eating the healthiest foods in moderate
amounts and sticking to regular mealtimes. A diabetes diet is a healthy-
eating plan that's naturally rich in nutrients and low in fat and calories.
Key elements are fruits, vegetables and whole grains.
Diabetes (only type 2, not type 1) can be managed with specific
lifestyle changes
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• The food you eat can affect your blood glucose level.
Therefore, you need to take a healthy diet with a low to moderate
amount of carbohydrate. Break up your 2 to 3 big meals into 4 to 5
smaller meals; can reduce blood-glucose spikes.
• Physical activity or regular exercise can help burn excess glucose
in your bloodstream, as well as reduce your insulin resistance (if
you have).
• Losing weight helps increase your insulin sensitivity, which has a
direct relationship with your blood-glucose control.
• Enough sleep can repair your body and nourishes the entire system,
additionally supports the management of your blood-sugar level.
• Stress is detrimental to your physical as well as mental health;
proper stress management helps you to attain your target blood
glucose level.

CARDIOVASCULAR DISEASES (CVD)

Cardiovascular diseases (CVDs) are a group of disorders of the heart and

blood vessels and they include coronary heart disease, arterial disease,
rheumatic heart disease, congenital heart disease etc.
Heart attacks and strokes are usually acute events and are mainly caused by a
blockage that prevents blood from flowing to the heart or brain. The most
common reason for this is a build-up of fatty deposits on the inner walls of
the blood vessels that supply the heart or brain. Strokes can also be caused by
bleeding from a blood vessel in the brain or from blood clots. The cause of
heart attacks
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and strokes are usually the presence of a combination of risk
factors, such as tobacco use, unhealthy diet and obesity, physical inactivity
and harmful use of alcohol, hypertension, diabetes and hyperlipidemia.
Risk factors A risk factor is something that increases your chance of getting
a disease. The more risk factors for coronary heart disease that you have, the
greater your chance of getting the disease.
Risk factors for coronary heart disease
Some risk factors are called modifiable, because you can do something about
them. There are other risk factors, called non- modifiable, which you can’t
change. However, many non- modifiable risk factors can be controlled and
their effect reduced by making changes to your lifestyle.
Modifiable and Non-modifiable risk factors
Modifiable risk factors include: smoking, high blood pressure
,diabetes, physical inactivity, being overweight, high blood cholesterol. The
good news is that the effect of many risk factors can be changed (you cannot
change the risk factor, only its effect). The effect of these modifiable risk
factors can be reduced if you make lifestyle changes.
Non-modifiable risk factors are: age, gender, ethnic background and
family history of heart disease.
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The Figure given below describes modifiable and non-modifiable
risk factors of cardiovascular diseases.

Fig: Risk factors of cardiovascular diseases

Prevalence – Cardiovascular diseases (CVDs) have now become the

leading cause of mortality in India. CVD death rates in India are
estimated to have risen from 155.7 to 209.1 per 100,000 between 1990
and 2016. Cardiovascular diseases (CVDs) take the lives of 17.7 million
people every year, 31% of all global deaths. Triggering these diseases –
which manifest primarily as heart attacks and strokes – are tobacco use,
unhealthy diet, physical inactivity and the harmful use of alcohol. These
in turn show up in people as raised blood pressure, elevated blood
glucose and overweight and obesity, risks detrimental to good heart
health.

Consequences The consequences of heart disease and stroke can be

fatal, but they can also lead to serious illness, disability, and lower quality
of life. Suffering a stroke may
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lead to significant disability, such as paralysis, speech
difficulties, and emotional problems. Following a heart attack,
individuals frequently suffer fatigue and depression, and they may find it
more difficult to engage in physical activities.

CVD management

Diet is an important risk factor in coronary heart disease. Food- related risk
factors include obesity, high blood pressure, uncontrolled diabetes and a diet
high in saturated fats. A low- saturated fat, high-fibre, high plant food diet can
substantially reduce the risk of developing heart disease. Heart healthy tips
include limiting dietary intake of processed and prepackaged ready to eat foods,
drinking water or unsweetened juices in place of sugary beverages and fruit
juices. An alternative to sweets and desserts after the meals is fresh fruit. A
variety of five handfuls of fruits and seasonal fruits and vegetables should be
consumed every day. Avoid or limit the consumption of alcoholic beverages.
Always pack and carry your own fresh and healthy school or office lunch.
Cardiovascular diseases (CVDs) take the lives of 17.7 million people every
year, 31% of all global deaths. Triggering these diseases – which manifest
primarily as heart attacks and strokes – are tobacco use, unhealthy diet, physical
inactivity and the harmful use of alcohol. These in turn show up in people as
raised blood pressure, elevated blood glucose and overweight and obesity, risks
detrimental to good heart health.
Therefore to reduce risk of CVD avoid tobacco use, consume healthy diet, be
regular in physical activity and avoid harmful use of alcohol as given in Fig
below.
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Fig: Strategies to reduce cardiovascular disease risk

CANCER:

Cancer is a condition of abnormal growth of cells with invasion of adjacent

tissues, structures and even distant sites. Eventually causing death of the
affected person if untreated or has become untreatable. Cancer can occur at any
site or tissue in the body. About two hundred types of cancers have been
reported in human. The major categories of cancer, on the basis of cell types,
are carcinoma, sarcoma, lymphoma, myeloma and leukemia. The term primary
tumor denotes the cancer in the organ or site of origin, while secondary tumors
are those which have spread to other organs or sites. When the growth of
cancerous cells attain a critical size it is clinically evident as a lump with, the
lump may ulcerate also. Moreover, the ulcer fails to heal. Known risk factors of
cancer are tobacco use, alcohol, exposure to harmful radiations, reproductive
factors, occupational exposure or hazards, unhealthy diet, certain harmful
microbes, obesity and family history are given in Fig:
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Fig : Risk factors of cancer

Prevalence Cancer mortality in India has doubled from 1990 to 2016.

India’s cancer incidence is estimated at 1.15 million new patients in 2018
and is predicted to almost double as a result of demographic changes alone
by 2040.

Primary prevention
The primary prevention operates by controlling the factors related to
some cancers, which are summarized as under
• Use of tobacco and alcohol consumption
• Maintaining personal hygiene
• Occupational exposures
• Toxic foods, drug, cosmetics
• Pollution etc.

Secondary prevention concerns with early detection and proper treatment

with adequate follow up and cancer registry.

Diet and Cancer

A diet high in whole foods like fruits, vegetables, whole grains, healthy fats
and lean protein may prevent cancer. Conversely, processed meats, refined
carbohydrates, salt and alcohol may increase your risk.
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Consequences of cancer

Cancer and its treatments can cause:

• Persistent hair loss
• Body image issues
• Depression, anxiety, loss of confidence
• Swallowing/speech problems
• Heart disease • Nausea, vomiting
• Urinary or bowel incontinence
• Lymphoedema and osteoporosis

Other typical long-term consequences include: fatigue & pain. Social and
financial difficulties are also common. These are given in Figure below.

Fig: Consequences of cancer and its treatment

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Cancer Education
It is very important part of primary prevention. It should be aiming at high
risk groups to look for early diagnosis and early treatment keeping the fact,
that this can save their live and mutilating physical social financial
complications by following of early warning signs :
• A lump or hard area in the breast or elsewhere which does not get
better
• A change in a wart or mole
• A persistent cough or hoarseness
• Excessive blood loss during or outside the usual dates
• Blood loss from any natural orifice
• A swelling or sore that does not heal
• Unexplained loss of weight.
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