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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
This presentation willreview • Nutritionally vulnerable periods in woman’s life • Effect of maternal under-nutrition on mother child dyad • Anaemia and its adverse effects • Magnitude of undernutrition in women
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.
There is no increase in dietary intake during lactation. • There is reduction in body weight and FFT during first year of lactation suggestingthat there is mobilisation of fat to meet the energy needs.Body weight improves after 12 months
Factors predisposing to maternal under-nutrition
NFHS-2 • Many adolescent girls have not completed their physical growth • If pregnancy occurs in early teens, there will be no further linear growth
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.
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
WW-working women HW Housewife Working at home and out side home imposes additional energy needs; if not met there is reduction in bodyweight
Maternal under-nutrition is associated with increased risk of low birth weight.
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
Effect of maternal nutrition on outcome of pregnancy Height (Cms.) Weight (Kg.) Hb (g/dl) Abortion rate % Birthwt. (Kg.) %LBW Low Income 151.5 45.7 10.9 12 2.70 33 Middle Income 156.3 49.9 11.1 8 2.90 20 High Income 156.3 56.2 12.4 6 3.13 15 Poor pregnancy outcome in low income groups is partly due undernutrition/ anaemia and partly due to poor ANC.
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
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
Average daily Per capita dietary intake Calorie Protein Fat Rural Urban Rural Urban Rural Urban 1972-73 2266 2107 62 56 24 36 1983 2221 2089 62 57 27 37 1993-94 2153 2071 60.2 57.2 31.4 42 1999-2000 2149 2156 59.1 58.5 36.1 49.6 Source: NSSO
Average Per Capita Calorie Intake by Expenditure Classes Expen-diture Classes Rural Urban 1972-73 1977-78 1993-94 1972-73 1977-78 1993-94 Lower 30% 1504 1630 1678 1579 1701 1682 Middle 40% 2170 2296 2119 2154 2438 2111 Top 30% 3161 3190 2672 2572 2979 2405
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 workprogrammes
Prevalence of anaemia Source: WHO • Global Developed DevelopingIndia • Urban Rural • Children<5 yrs4312516070 • Children > 5yrs377465060 • Men183263545 • Women3511475060 • Pregnant 59145165 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.
Prevalence of anaemia is high in South Asia. Even among South Asian countries prevalence of anaemia in pregnancy is highest in India.
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.
India’s 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.
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 anaemiain all age groups.
Anaemia is a major problem right from childhood; it worsens during adolescence in girls Advent of pregnancy further aggravates anaemia
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
Prevalence of anaemia is high even in high income groups and among well educated pregnant women.
Time trends in intake of iron, folic acid and vitamin C in rural and urban areas (c/day) – (NNMB) 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%.
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.
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.
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 • <5 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 • <5 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 <5 g%.
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 <8 g%.
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 <8g/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.
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
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.
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 < 5 g/dL • Constitute 5- 10% of anaemic women, • Admission and intensive care preferably in secondary or tertiary care institutions to ensure maternal and fetalsalvage. • 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).
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.
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.
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.
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.
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.
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.