Nutrition policy

1. State the vision and goals of nutrition policy.

Vision : The people of Bangladesh will attain healthy and productive lives through gaining
expected nutrition .

Goal

1. To improve the nutritional status of the people, especially disadvantaged groups,

including mothers, adolescent girls and children

2. To prevent and control malnutrition; and

3. To accelerate national development through raising the standard of living

Objectives

1. Improve the nutritional status of all citizens, including children, adolescent girls,
pregnant women and lactating mothers

2. Ensure availability of adequate, diversified and quality safe food and promote healthy
feeding practices

3. Strengthen nutrition-specific, or direct nutrition interventions

4. Strengthen nutrition-sensitive, or indirect nutrition interventions

5. Strengthen multisectoral programs and increase coordination among sectors to ensure

improved nutrition

2, Discuss nutrition specific intervention for children, adolescent girls and women.
Ans. Nutrition-specific or direct interventions for children :

It include the promotion of:

1. Exclusive breastfeeding during the first 6 months after birth

2. Providing complementary food after age 6 months, appropriately prepared at

home, alongside breastfeeding ,

3. Washing hands with soap before feeding a child

4. Vitamin A supplementation for children every 6 months

 5. Supplementation with other micronutrients

6. Providing zinc as part of diarrhea treatment

7. Treatment of moderate or severe acute malnutrition

Nutrition-specific or direct intervertion For adolescent girls and women

Nutritional status is being improved through a behavior change communication

to provide nutritional knowledge through counselling at family level

1. Provision of iron, folic acid or multiple micronutrients

as supplements, as appropriate

2. Promotion of the use of iodized salt

3. Promotion of the use of calcium during pregnancy as a supplement; and

4. Preventative activities in educational institutions and communities to avert

incidences of overweight and obesity

Indicators for achieving optimal nutrition

 Increase the initiation of breastteeding in the first hour of life

 Increase the rate of exclusive breastfeeding in infants younger than age 6 months
 Increase the rate of continued breastteeding in children aged 20 to 23 months
 Increase the proportion of children aged 6-23 months receiving a minimum
acceptable diet
 Reduce the rate of low birth weight
 Reduce stunting among under-5 children
 Reduce wasting among under-5 children
 Reduce the proportion of underweight among under-5 children
 Reduce the rate of severe malnutrition among children
 Reduce malnutrition among adolescent girls
 Increase Vitamin A coverage
 Reduce malnutrition among pregnant women and lactating mothers
 Increase the rate of iodized salt intake
 Reduce maternal overweight (BMI>23)
 Reduce the rate of anemia among women
 Supplementary feeding

Supplementary feeding

 Supplementary feeding may be defined as providing extra food to people or families

beyond the normal ration of their home diet .
 Supplementary feeding is used in both emergency and non-emergency situations to
address short-term hunger, longer-term food shortage, and to improve the nutritional
status (or prevent the nutritional deterioration) of specific populations ,
 Sometimes authorities provide food supplementation to increase use of health
services, adherence to treatment regimens or attendance (and performance) at school.
 In humanitarian disasters, food aid aims to relieve absolute food shortage

Types of Supplementary feeding

1. Blanket supplementary feeding

 Aims to prevent malnutrition or its progression in food insecure populations

 The targeting is based on knowing that the population is high risk
 Food is given to the whole at-risk population without prior screening (UNHCR/WFP
1999)

2. Targeted supplementary feeding

 Directed at selected people who are at risk

 Treating mild or moderate malnutrition detected by screening at-risk populations
 Providing supplementation only to people who fall below a pre-specified nutritional
status threshold.

Blanket supplementary feeding is a temporary solution to stop the nutritional condition of

high-risk populations from deteriorating, such as elderly people, pregnant women,
breastfeeding mothers, young children, and women at risk for HIV/AIDS. The World Food
Programme, UNHCR, and implementing organizations collaborate to ensure the prompt
delivery of a sufficient general food ration in emergencies. However, subpopulations that are
either currently malnourished or have a high risk of becoming malnourished may require
additional meals for a while. For example, at the outset of a food emergency when the food
pipeline for the general food ration is still insufficient, blanket supplementary feeding should
be taken into consideration.

Targeted supplementary feeding, according to established cut-off criteria (Mid-Upper-Arm

Circumference(MUAC) 12.5 cm or weight of 70% to 79% weight-for-height), is given to
elderly people, pregnant women in their second or third trimester, lactating women up to six
months after giving birth, and children aged six months to five years who are acutely
malnourished. Families affected by HIV/AIDS are one particular category that is causing
much worry. The goal of targeted supplementary feeding is to reduce the need for broad
therapeutic feeding, especially among children, and to prevent severe acute malnutrition
among moderately malnourished individuals. On a small scale, targeted supplementary
feeding is frequently used.

Objectives of Supplementary Feeding:

1. to stabilize or improve the nutritional status of beneficiaries in order to prevent
growth failure and malnutrition
2. Maternal supplements of balanced energy and protein improves maternal and
child undernutrition in food insecure contexts
3. Providing supplements to pregnant women of low body-mass index can
reduce the risk of small-forgestational age baby by 32% Providing 99%
coverage of balanced energy protein supplementation in the 36 priority
countries could substantially reduce the burden of disease
 4. To close the energy and nutrient gap by 100%

5. To improve KAS of mother or caregiver on nutrition, proper

feeding of their children

6. Rehabilitate moderately malnourished person

7. Reduce mortality and morbidity risk in children under 5 years

8. Provide a food supplement to selected Pregnant and nursing

mothers and other individual at-risk

9. Provide follow-up to referrals from Therapeutic Feeding Program

10. To enable the young children to have concept to have concepts on

good nutrition
11. Reduction of severe protein -energy malnutrition (PEM) in under 2

children by 50 percent.
12. Reduction of moderate Protein Energy Malnutrition among Under

2 children by one-third
13. Reduction of low birth weight (LBW) incidence by 50 percent

14. Improvement in weight gain to 7.0 kg in at least 50 percent of

pregnant women
15. To lay the foundation for proper psychological, physical and social

development of the children

Standards for starting and stopping emergency supplementary feeding

Blanket supplementary feeding

When to start:  

1. When an emergency first arises, before the food pipeline and general food ration are
improved and sustained.
2. Scurvy, beriberi, or pellagra outbreaks among the target group.
When to close:

 When the distribution of food rations and the food pipeline are sufficient.

 When the target population is free of scurvy, beriberi, or pellagra cases.

Targeted supplementary feeding

  When to start :  When there is a need for large-scale therapeutic feeding and to
prevent a decline in the nutritional health of the population’s most vulnerable
groups (children under five, pregnant women, nursing women, families affected by
HIV/AIDS, and the elderly). 

 When to stop : When the rate of acute malnutrition around the world is steady or
decreasing.

Food fortification

Fortification is the practice of deliberately increasing the content of one or more

micronutrients (i.e. vitamins and minerals) in a food or condiment to improve the
nutritional quality of the food supply and provide a public health benefit with minimal
risk to health.

• As well as increasing the nutritional content of staple foods, the addition of

micronutrients can help to restore the micronutrient content lost during processing

• Fortification is an evidence-informed intervention that contributes to the prevention,

reduction and control of micronutrient deficiencies

• It can be used to correct a demonstrated micronutrient deficiency

 in the general population (mass or large-scale fortification) or

 in specific population groups (targeted fortification) such as children, pregnant
women and the beneficiaries of social protection programs
 When the vitamins and minerals are not added to the foods during the processing but just
before consumption at home or at schools or child‐care facilities, it is called point-of-use
fortification
 Fortifying Commercial food

Biofortification

• Biofortification is the idea of breeding crops to increase their nutritional value

• Breeding of crops with higher levels of vitamins and minerals or higher proteins and
healthier fats

• Can be done either through conventional selective breeding , or through genetic

engineering
 • differs from ordinary fortification because it focuses on making plant foods more
nutritious as the plants are growing, rather than having nutrients added to the foods
when they are being processed

• important improvement on ordinary fortification when it comes to providing nutrients

for the rural poor, who rarely have access to commercially fortified foods

• seen as an upcoming strategy for dealing with micronutrient deficiencies in low and
middle income countries

• In the case of iron, the WHO estimated that biofortification could help curing the 2
billion people suffering from iron deficiency induced anemia .

Food based income transfer

 Efforts to enhance food and nutrition security in both relief and development contexts
typically involve resource transfers to needy population
 A significant part of such transfers comprise in kind food aid, but cash transfers are
rapidly growing in importance .
Food based income transfer
 Food aid as well as cash transfers are provided in many countries
1. through mother and child health programs aimed
- to address malnutrition
- to improve primary and secondary school enrolments, and other
related developmental outcomes
2. countries facing recurrent natural disasters that result in loss of life
and livelihoods- typical response involves transfer of food to needy
populations, aiming to assure their food and nutrition security.
Uses of transfer depends on
(i) the size of the transfer to the household
(ii) the extent to which households are likely to use the additional resource to
increase food consumption
(iii) who controls the transfer within the household Any intervention therefore
needs to be carefully analyzed in light of the local context.
The final decision as to what type of transfer to apply (cash, food or a combination of the
two) should necessarily be taken in relation to program objectives (effectiveness) .

Cash seems to be most appropriate

 when markets work adequately
 when food is available and affordable
 when prices are relatively stable and predictable (i.e. when macroeconomic
conditions are stable)
 when there is a basic financial infrastructure
 when there is appropriate capacities in delivery and monitoring
 when there are adequate contingency plans; and after harvest.
Cash seems to be least appropriate
• when the mentioned conditions do not hold
• to be less appropriate in situations of limited levels of education
• Highly unstable conditions in early stages of emergencies
Cash transfers to food-insecure populations seem to be spent primarily on food
The predictability, stability, timing and amount of cash transfers matter importantly to
household preferences for or against cash (over food)
Distance from markets and seasonal and gender factors also seem to be important
determinants of beneficiary preferences.
Beneficiary preferences for cash or food
1. Location :
 People living in remote areas tend to prefer food transfers
 closeness to markets makes it easier to spend cash on the desired goods
2. Season :
 In relief situations, cash is said to be more appropriate right after the harvest,
when food is likely to be available in markets
 food is said to be preferred during the lean season, or ‘hungry period’
3. Gender : Cultural habits on the management of cash resources within the households
make women more likely to prefer food transfers
Food security is broadly defined as physical and economic access by all people at all times
to sufficient food to meet their dietary needs for a healthy and productive life.
essential elements of food security
1. availability of adequate food at a national
2. access to adequate food at household and individual levels
3. effective biological use of food, which depends on factors, such as the health and
sanitation environment

Nutrition-sensitive value chains

 Nutrition-sensitive value chains can occur along the consumption side of the food and
agriculture sector framework through nutrient enhancement during food processing
 provide an opportunity for fortification of grain products, such as wheat or maize
flour. Fortification of wheat flour with folic acid is one example of post harvest
fortification
• Value chain interventions :
 especially adept to be able to target specific micronutrient deficiencies
 will have less of an impact on holistic diets as they generally only focus on
one food at a time .
 interventions in a nutrition-sensitive value chain can create rural–urban linkages by
ensuring that
 agricultural producers receive increased income from their products
 urban consumers receive products that are fresh and nutritionally beneficial
 have the potential to address food-borne illnesses through food safety
interventions, which will have a positive outcome on nutritional
status enhanced storage techniques or fortification
 to prolong the shelf life of foods with high nutritional value (Cheema et al.,
2018), such as fruits and vegetables
 To prevent food loss and waste
 Mainstreaming and scaling up nutrition services

• The Government of Bangladesh (GOB) formulated the 5year (July 2011–June 2016)
health sector plan, the “Health, Population and Nutrition Sector Development
Program” (HPNSDP), which includes an operational plan for mainstreaming and
scaling up nutrition services nationally .

• This is a major shift from the government’s previous strategy, and for the first time
nutrition will be mainstreamed and scaled up through the National Nutrition Services, in
co-ordination with relevant ministries

Steps the Government of Bangladesh Can Take to Mainstream Nutrition

• Ensure adequate skilled staff are available at all levels for service delivery

• Develop a strong supervision and monitoring system to assess progress on food

security and nutrition

• Ensure a structure is in place to integrate nutrition into the health system at every
level

• Strengthen multi-sectoral co-ordination across ministries to mainstream nutrition

• Let development partners know how we can support the GOB more effectively
 Steps the Government of Bangladesh Can Take to Mainstream Nutrition

• Ensure that the health system has capacity to manage acute malnutrition cases

• Promote diversity in food production

• Finalize a food safety and quality policy and action plan

• Improve food storage and processing and reduce waste

• Implement behaviour change communication strategies to improve hygiene

and sanitation practices, including hand-washing

• The Annual Program Review (APR) of HNPSP in 2009 recommended that to scale up
the nutrition interventions the only option is to mainstream the critical nutrition interventions
in the services provided through DGHS and DGFP.

• If the present model of NNP is continued country wide by contracting NGOs, the cost
for NNS interventions will be about Tk. 5000.00 crore and it would not possible to achieve
MDG target by 2015 with the implementation of the existing model

• In light of this situation, the Government of Bangladesh has planned to accelerate the
progress in reducing the persistently high rates of maternal and child under nutrition by

 mainstreaming the implementation of nutrition interventions into health

(DGHS) and family planning services (DGFP),
 scaling-up the provision area-based community nutrition
 updating the National Plan of Action on Nutrition in the light of food and
nutrition policies
To achieve this, nutrition has been made a priority for the proposed sector program and a
variety of key strategies and actions will be pursued

The mainstreamed program will be guided by 2 main principles

• The program will focus on those activities within its mandate and where it has the
capacity as well as the comparative advantage to act.

• The key activities that lie outside the mandate of the health sector, NNS will play a
coordination as well as advocacy role and ensure active engagement with other the
key sectors (for example, Ministries of Agriculture, Food and Disaster Management,
Ministry of Industry, etc)
 • The nutrition program will seek to intervene at the different stages of the lifecycle
– during pregnancy, at delivery/neonatal, post natal, childhood, adolescence,
newly weds .but with a strong focus on the “window of opportunity”, that is,

pregnancy through first two years of life.

Food security is broadly defined as physical and economic access by all people at all times
to sufficient food to meet their dietary needs for a healthy and productive life.

essential elements of food security

4. availability of adequate food at a national

5. access to adequate food at household and individual levels
6. effective biological use of food, which depends on factors, such as the health and
sanitation environment

Consequences of iron deficiency and anaemia throughout the life cycle

All individuals :

 Poor immune function and increased morbidity from infections

 Fatigue and lower physical work capacity
 Poor concentration and impaired cognitive performance
 Poor quality of life

Infant , preschool and school age children

 Poor physical growth, cognitive development and school achievement

 Increased risk of infant and child death
 Increased risk of iodine deficiency
 Low or depleted iron stores for future pregnancies in adolescent girls

Pregnant women and their foetuses

 Increased risk of complications during delivery, including prolonged labour,

preterm delivery, LBW and maternal and neonatal death
 Infants of mothers with iron deficiency anaemia are more likely to have low
iron stores and to become anaemic in infancy and childhood .
 Targeted strategies for high-risk groups

 Strategy 1 : Micronutrient supplementation

 Strategy 2 : Dietary improvement
 Strategy 3 : Parasitic disease control
 Strategy 4 : Family planning and safe motherhood

Population-based strategies

 Strategy 5 : Food fortification

 Strategy 6 : Production of micronutrient-rich foods through household food
production, crop diversification, biotechnology and biofortification .

Strategy 1 : Micronutrient supplementation

 Provide iron-folate (IFA) or multiple micronutrient (MMN) supplements to low birth weight infants
aged 2-5 months and all children aged 6-23 months, pregnant women, and breastfeeding women for
the first three months after delivery, adolescent girls and newly wed women in the recommended
dose and frequency.
 If resources are available, provide IFA or MMN supplements to other vulnerable groups, such as
children aged 24-59 months, school-aged children and non-pregnant women of reproductive age in
the recommended dose and frequency.
 Counsel women and caregivers on how to take the IFA/MMN supplements, the importance of taking
the full dose, and help them solve any problems they have in complying, such as managing side
effects.
 Screen all children, adolescent girls and women for severe anaemia at every contact with a health
service provider using the most appropriate and feasible screening method at the health care level.
Provide appropriate treatment for anaemia or refer children and women for treatment.
 In emergencies, provide MMN supplements or therapeutic spreads to children aged less than 5 years,
pregnant women, and breastfeeding women.

Strategy 2 : Dietary improvement

 Protect, promote and support breastfeeding and complementary

feeding practices, including

 Initiation of breastfeeding immediately after delivery (within half an hour)

 Exclusive breastfeeding for the first six months (180 days) of life
 Timely and appropriate introduction of complementary feeding on completion of six months
(180 days) of life
  Continued breastfeeding until the child is at least 2 year

Strategy 3 : Parasitic disease control

 Provide presumptive anthelmintic treatment to children aged 24-59 months2 and

adolescent girls once every six months.
 Provide a single dose of presumptive anthelmintic treatment to pregnant
women at the earliest opportunity in the second trimester. If the local
prevalence of hookworm infections is >50%, provide a second dose of
anthelmintic treatment at the earliest opportunity after delivery.
 If resources allow, provide anthelmintic treatment to children aged 5-11 years
every six months.
 Provide information to women and caregivers on home care of diarrhoea
(oral rehydration therapy and continued feeding), the danger signs of
severe diarrhoea, and when and how to seek medical care.
 Promote good hygiene and sanitary practices to prevent infection,
including the use of shoes and latrines, and hand washing after defecation,
before food preparation and before eating.

Malaria (areas of malaria transmission only)

 Provide information to women and caregivers on the danger signs of malaria, and
when and how to seek treatment.
 Provide rapid malaria treatment to young children and pregnant women with
symptoms of fever or malaria in line with national malaria management protocol
 Promote protection measures against malaria (use of insecticide-treated bed-nets,
particularly by pregnant women and children aged less than 5 years, and
environmental control of mosquitoes)

Strategy 5 : Food fortification

 Set legislation and regulations for fortification with iron and other micronutrients.
 Develop, produce and market foods fortified with iron and/or other micronutrients
(including folic acid, vitamin B-12 and vitamin A) for the general population.
 Develop, produce, and market low cost foods fortified with iron and/or other
micronutrients for specific vulnerable groups, particularly infants and young children.
  Fortify food aid products for development and emergency response programmes with
iron and other micronutrients, including school-feeding programmes.
 Promote (through social marketing) foods fortified with iron and other micronutrients.

Strategy 6 : Production of micronutrient-rich foods

 Promote year-round production by households of micronutrient-rich foods or crops in

home gardens, fruit tree plantation, small animal husbandry and fisheries.
 Promote the development of new varieties of staples that are rich in micronutrients
(biotechnology and biofortification)

Non nutritive sweeteners

Non nutritive sweeteners are no-calorie or low-calorie artificial and natural sweeteners that
have been developed as an alternative to sugars .

The FDA approved five NNSs :

 Saccharin
 Aspartame
 Acesulfame-K
 Sucralose
 Stevia

Characteristics of Non-nutritive sweeteners :

 Analysis of national health and nutrition examination survey data that NNs are high
intensity, low calorie, high potency, and non nutritive.
 This intense sweetness allow for smaller portion yield sugar like sweetness in food
products.
 Food manufacturer label them as virtually sugar free or non-calorie.
 Use of NNs is that individuals struggling with obesity can enjoy the food and
beverages without the risk of consuming additional calories.
 Growing concern about NNs about health and quality of life encouraged people to
avoid consumption of food rich in sugar, salt and fat.

So food product contains calorie free alternatives have become popular.

 Usually NNS synthetics, some are natural.

Benefits of Non-nutritive sweeteners

 Weight control
 Diabetes control
 Prevent tooth decay
 Pleasant taste without increasing energy intake.
 Can be used to replace sugar in cooking or baking.
 Decrease calorie content of food.
 Only require small amount to sweeten foods and beverages.

Disadvantages of Non-nutritive sweeteners

 They may cause an aftertaste.

 There is limited research on the safety during pregnancy.
 Sweetener or sweet taste may increase appetite
 They may alter metabolism, which could lead to overeating .

So, to dramatic increase in consumption of NNS concerned has been raised

about potential health effect.

Obesity

Overweight or obesity is defined as abnormal or excessive fat accumulation that presents a

risk to health

Causes of Obesity :

 Genetic causes : Mutation of leptin gene or leptin receptor gene

 Prenatal over nutrition- e.g. maternal obesity, gestational diabetes

 High energy diet and over eating: daily excess of 100 kcal(equivalent to a small
chocolate bar) leads to increased body weight by 5kg over 1 year and 50 kg over
10 years.

 Lack of physical activity: Sedentary life style, More involvement with media
time.
  Endocrine causes : Thyroid disorder, Cushing syndrome, growth hormone
deficiency

 Drugs: steroid, anticonvulsant, antidepressants, anti phychotics.

Diagnosis of obesity

 Body mass index

 Waist circumference: male≥94cm, female≥80 cm

 Waist hip ratio: Male <1.0, female<0.85

 Measurement of body fat content: MRI, Computed axial tomography scan

(CAT SCAN)

Treatment & prevention

 Life style change

 Anti obesity drug

 Surgical treatment

Prevention

 Eat healthy diet-low fat die high fiber(fruit and vegetables) whole grain, nut

 Adopt physically active healthy life

 Avoid alcohol consumption

 Limit intake of CHO, sugar free diet(now NNs show healthy and beneficial effect.)

Dietary Fiber
Write down consequences of over nutrition. 'Obesity is a leading nutritional problem'-
Justify?

Figure 1 : Conseauences of over nutrition

 Obesity is a leading nutritional problem / What are the health
consequences of being overweight ?

 The latest WHO projections indicate that at least one in three of the world's adult
population is overweight and almost one in 10 is obese. Additionally, there are over
40 million children under age five who are overweight.
 Being overweight or obese can have a serious impact on health. Carrying extra fat
leads to serious health consequences such as :
16. Cardiovascular disease (mainly heart disease and stroke)
17. Type 2 diabetes
18. Musculoskeletal disorders like osteoarthritis
19. some cancers (endometrial, breast and colon).

These conditions cause premature death and substantial disability.

The risk of health problems starts when someone is only very slightly overweight,
and that the likelihood of problems increases as someone becomes more and more
overweight. Many of these conditions cause long-term suffering for individuals and
families. In addition, the costs for the health care system can be extremely high.

Economic & Social Development

Nutrition-sensitive interventions within the food and agriculture sector
Three important interventions
 fortification
 home production
 nutrition-sensitive value chains

▪ The interventions of fortification and nutrition-sensitive value chains are focused on

the population level .
▪ Home production is an intervention that is focused on the household level
Multiple ways for nutrition programs to provide fortification :

 can occur on the production side (commonly referred to as biofortification), where

farmers grow biofortified or nutrient-dense varieties that have been modified to
address a nutrient deficiency.

Examples include

 high iron pearl millet in India (Birol et al., 2015)

 improved (high yielding) maize varieties in Malawi (Bezu et al., 2014)
 to integrate food and nutrition security through plant breeding (Christinck &
Weltzien, 2013; Listman et al., 2019)
 fortification via fertilizers, often referred to as agronomic fortification

The Geo Nutrition Project has demonstrated results that micronutrient deficiencies of
selenium can be alleviated through adding selenium fertilizers to staple cereal crops in
Malawi (Joy et al., 2019) .

Write down the impact of nutritional anemia. Mention the strategies for prevention of
nutritional anemia in Bangladesh.
Distinguish between bulimia nervosa and binge eating disorder.

Double burden of malnutrition

 The double burden of malnutrition is the coexistence of over-nutrition (overweight and

obesity) alongside under-nutrition (stunting and wasting), at all levels of
the population—country, city, community, household, and individual

 Malnutrition in its many forms has previously been understood and approached as a
separate public health issue

 new emergent reality is that under-nutrition and overnutrition are interconnected and,
therefore, double-duty actions that simultaneously address more than one dimension
must be implemented for policy solutions to be effective

 The DBM affects all countries, rich and poor

 At the population level, women are most affected by the DBM
 most countries have more overweight than underweight women
 at the household level, with stunted children coexisting with overweight/obese women- is
mostly commonly found in Latin American countries (<10%)
 At the individual level- the most common form of DBM seems to be energy over-
nutrition and iron deficiency, is found even in the United States
 The consequences of the DBM

• Early life under-nutrition is an underlying cause associated with about a third of young
child deaths

• Among the survivors that become stunted in the first two years of life, their capacity to
resist disease, to carry out physical work, to study and progress in school, are all
impaired across the life course

• Later in the life course, diet and nutrition, and especially obesity, are important
underlying causes of many noncommunicable diseases (NCDs), including hypertension,
diabetes, cancer, stroke, and ischemic heart disease
• NCDs are responsible for the majority of deaths worldwide and are disproportionately
high in LMICs where nearly 80 percent of NCD deaths occur
• Nearly half of NCD deaths in 2008 were caused by cardiovascular disease (CVD)
• The metabolic syndrome, in which abdominal obesity and type 2 diabetes play a central
role, is associated with a doubling of cardiovascular disease risk
• The costs of treating the metabolic syndrome are considerable and growing, consuming
increasingly larger proportions of health budgets in both LMICs, and higher income
countries
Define Mainstreaming and Scaling Up of Nutrition.

Mention the principles of mainstreamed program of nutrition.

Elaborate the related strategies in program implementation plan.

 Eating disorders
Eating disorders are a range of psychological conditions that cause unhealthy eating habits to
develop which might start with an obsession with food, body weight, or body shape. 

1. Anorexia nervosa:
 Anorexia nervosa is likely the most well-known eating disorder.
 It generally develops during adolescence or young adulthood and tends to
affect more women than men .
 People with anorexia generally view themselves as overweight, even if
they’re dangerously underweight. They tend to constantly monitor their
weight, avoid eating certain types of foods, and severely restrict their calorie
intake.
 Common symptoms:

1. Very restricted eating patterns

2. Intense fear of gaining weight or persistent behaviors to avoid gaining

weight, despite being underweight.

3. A relentless pursuit of thinness and unwillingness to maintain a healthy

weight.

4. A heavy influence of body weight or perceived body shape on self-

esteem
 5. A distorted body image, including denial of being seriously
underweight.

6. Obsessive-compulsive symptoms are also often present. For instance,

many people with anorexia are preoccupied with constant thoughts
about food, and some may obsessively collect recipes or hoard food.

2. Bulimia nervosa :

 Bulimia nervosa is another well-known eating disorder.

 Like anorexia, bulimia tends to develop during adolescence and early adulthood and
appears to be less common among men than women .People with bulimia frequently
eat unusually large amounts of food in a specific period of time.
 Common symptoms:

 Recurrent episodes of binge eating with a feeling of lack of control

 Recurrent episodes of inappropriate purging behaviors to prevent weight gain

 Self-esteem overly influenced by body shape and weight

 A fear of gaining weight, despite having a typical weight

 In severe cases, bulimia can also create an imbalance in levels of electrolytes,

such as sodium, potassium, and calcium. This can cause a stroke or heart
attack.
 3. Binge eating disorder

 Binge eating disorder is the most prevalent form of eating disorder and one of
the most common chronic illnesses among adolescents.

 It typically begins during adolescence and early adulthood, although it can

develop later on.
 Individuals with this disorder have symptoms similar to those of bulimia or the
binge eating subtype of anorexia.

 Common symptoms :

 Eating large amounts of food rapidly, in secret, and until uncomfortably full,
despite not feeling hungry

 Feeling a lack of control during episodes of binge eating

 Feelings of distress, such as shame, disgust, or guilt, when thinking about the
binge eating behavior

 No use of purging behaviors, such as calorie restriction, vomiting, excessive

exercise, or laxative or diuretic use, to compensate for the binge eating .

4. Pica

 Pica is an eating disorder that involves eating things that are not considered food and
that do not provide nutritional value .
 Individuals with pica crave non-food substances such as ice, dirt, soil, chalk, soap,
paper, hair, cloth, wool, pebbles, laundry detergent, or cornstarch.
 Pica can occur in adults, children, and adolescents.
  It is most frequently seen in individuals with conditions that affect daily functioning,
including intellectual disabilities, developmental conditions such as autism spectrum
disorder, and mental health conditions such as schizophrenia .
 Individuals with pica may be at an increased risk of poisoning, infections, gut injuries,
and nutritional deficiencies. Depending on the substances ingested, pica may be fatal.

5. Rumination disorder

 It describes a condition in which a person regurgitates food they have previously

chewed and swallowed, re-chews it, and then either re-swallows it or spits it out .
 This rumination typically occurs within the first 30 minutes after a meal .
 This disorder can develop during infancy, childhood, or adulthood. In infants, it tends
to develop between 3 and 12 months of age and often disappears on its own. Children
and adults with the condition usually require therapy to resolve it.
 If not resolved in infants, rumination disorder can result in weight loss and severe
malnutrition that can be fatal.
 Adults with this disorder may restrict the amount of food they eat, especially in
public. This may lead them to lose weight and become underweight (16). 

6. Avoidant/restrictive food intake disorder :

 Avoidant/restrictive food intake disorder (ARFID) is a new name for an old disorder.
 The term has replaced the term “feeding disorder of infancy and early childhood,” a
diagnosis previously reserved for children under age 7 .
 Individuals with this disorder experience disturbed eating due to either a lack of
interest in eating or a distaste for certain smells, tastes, colors, textures, or
temperatures.
 Common symptoms of ARFID include :

 avoidance or restriction of food intake that prevents the person from eating
enough calories or nutrients
  eating habits that interfere with typical social functions, such as eating with
others

 weight loss or poor development for age and height

 nutrient deficiencies or dependence on supplements or tube feeding

Other eating disorders

In addition to the six eating disorders above, other less known or less common eating
disorders also exist. 

 Purging disorder. Individuals with purging disorder often use purging behaviors,

such as vomiting, laxatives, diuretics, or excessive exercising, to control their weight
or shape. However, they do not binge.

 Night eating syndrome. Individuals with this syndrome frequently eat excessively at

night, often after awakening from sleep. 

 Other specified feeding or eating disorder (OSFED). While it is not found in the

DSM-5, this category includes any other conditions that have symptoms similar to
those of an eating disorder but don’t fit any of the disorders above. 

Eating disorder treatment

 Eating disorder treatment plans are specifically tailored to each person and may
include a combination of multiple therapies. 
 Treatment will usually involve talk therapy, as well as regular health checks with a
physician
 It’s important to seek treatment early for eating disorders, as the risk of medical
complications and suicide is high ,

Treatment options include : 

  Individual, group, or family psychotherapy : A type of psychotherapy
called cognitive behavioral therapy (CBT) may be recommended to help reduce or
eliminate disordered behavior such as binge eating, purging, and restricting. CBT
involves learning how to recognize and change distorted or unhelpful thought
patterns.

 Medications : Antidepressants, antipsychotics, or mood stabilizers to help treat an

eating disorder or other conditions that may occur at the same time, such as
depression or anxiety .

 Nutritional counseling. This involves working with a dietitian to learn proper

nutrition and eating habits and may also involve restoring or managing a person’s
weight if they have experienced significant weight changes. Studies suggest that
combining nutritional therapy with cognitive therapy may significantly improve
treatment outcomes.

 Listening to them. Taking time to listen to their thoughts can help them feel heard,
respected, and supported. Even if you don’t agree with what they say, it’s important
that they know you’re there for them and that they have someone to confide in. 

 Including them in activities. You can reach out and invite them to activities and social
events or ask if they want to hang out one-on-one. Even if they do not want to be
social, it’s important to check in and invite them to help them feel valued and less
alone.

 Trying to build their self-esteem. Make sure they know that they are valued and
appreciated, especially for nonphysical reasons. Remind them why you are their
friend and why they are valued. 

Lactose intolerance

 Lactose intolerance means the body cannot digest lactose. This is

not food allergy to milk.
• When lactose moves through the large intestine without being properly
digested, it can cause uncomfortable symptom such as gas, belly pain,
bloating .
Types of Lactose intolerance
 1. Primary lactase deficiency :
 is a genetically determined absence or decrease of enzyme .
 Jejunal morphology is normal .
 In non Caucasian group PLD is abnormal in adulthood .
2. Secondary, acquired, or transient lactase deficiency :
 is due to the small intestinal mucosal disease, abnormalities of brush border
cell and transport process .
 It is often associated with celiac sprue .

3. Congenital lactase intolerance

 Vary rare

 Autosomal recessive genetic disorder that prevent lactose tolerance from 1st
feed
 Infant fail to thrive unless given lactose free formula feed.
Symptoms

• Can be mild to moderate, depending how much lactase body can make. Symptom
usually begin 30 minutes to 2 hours after drinking milk or milk product.If have, LI
may include
• Bloating
• Pain
• Crump
• Gurgling or rumbling sound in belly
• Diarrhea
Diagnosis

• Dietary history
• Family History
• Patient has underwent partial gastrectomy and other related procedure
• Test
• Stool acidity test, Hydrogen breath test
Treatment :
There is no cure for Lactose intolerance but treatment is by limiting or avoiding milk
& milk products. Some people use milk with reduce milk or substitute soy milk, soy
cheese for milk or milk product.

Disease Treatment
 There is no cure for Lactose
intolerance but treatment is by
limiting or avoiding milk & milk
Lactose intolerance
products.
 Some people use milk with reduce
milk or substitute soy milk, soy
cheese for milk or milk product.
 Control by nutritional therapy,
mainly both galactose and lactose
free diet.
Galactosemia and galactosuria
 Infant should fed soya formula.
 Continued dietary restriction of
dairy products in older child

 Vit C and low protein diet.

Alkaptonuria  Newborn screening
 Oral nitisinone therapy may helpful.

 Dietary leucine restriction,

 supplementation with isoleucine and
valine.
Maple syrup disease
 Frequent clinical and biochemical
monitoring

 Restricting the intake of

phenylalanine in diet and maintain
 Phenylketonuria the level within 2-6mg/dl.
 The adjuvant therapy with
saproprotein is also helpful for PKU.
Gaucher disease Enzyme replacement therapy
Adequate nutrition with low cholesterol
Nieman-pick disease diet. No effective Rx, but stem cell
transplantation may help.
Glycogen storage Disease