A Tool for Self Assessment of Food Intake and

ANNAM 2010 National Seminar on Health, Food & Agro biodiversity Changing Paradigms

A Tool for Self Assessment of Food Intake and Therapeutic Diet Jayakrishnan T1 and Thejus T J2 1 Dept. of Community Medicine, Medical College, Calicut 2 All India Institute of Medical Sciences, New Delhi 1 [email protected], 2 [email protected]

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he dietary allowances of nutrients for a countrys population are recommended based onthe current knowledge on nutritional requirements of different age and sex groups and thecountrys food and dietary habits (1) . The consumed food, in quality and quantity is oneof the important determinants of health. India being a developing country we are facingunder nutrition as well as over nutrition. Over nutrition is one of the important modifiablerisk factor of life style diseases like obesity, diabetes, hypertension and stroke

fueled by globalization, urbanization and commercializationof food trades. In the present scenario the nutritional transition towards refined foods,foods of animal origin and increased fat play a major role. In this context as a healthpromotion and preventive measure every person have to be aware of the importance offood in take and its impacts on their own health to make a healthy choice. Since Kerala state is in the late phase of health transition the prevalence of life style diseases are veryhigh, comparable to developed countries Table 1.

(3). So the Doctors, health care persons,dieticians have to be equipped with the Table: Table: 1. Kerala: Chronic disease morbidity knowledge and skill of therapeutic diet. Rate per 1000. (Total 102/1000person) (2). Thisepidemic of over nutrition is

Disease: Rural Hyper tension 47.3 Diabetes mellitus 25.5 Asthma 29 Joint problems 16 Heart disease 11 Epilepsy 12.7 Stroke 3.6 Cancer 1.8 Allergy 1.8 TB 1.8

Urban 21.6 31.6 9.9 8.3 10 5 0 1.6 4.9 0

Total 34 28.6 20 12 10.4 6 1.7 1.7 3.5 0.8

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Presently the nutritional counseling is done on the text books based on western literaturewhich is not applicable to our context. The Indian standard nutritional recommendationsare prepared by scientists working at National Institute Nutrition (NIN)


Hyderabad andIndian Council of Medical research ICMR Delhi which are based on north Indian diet andhabits(4). In health facilities therapeutic diet counseling is a neglected part of patient provider interaction. So no practical tool for nutritional counseling was available forsouth Indian state like Kerala where the burden of life style diseases are high and alsowhere the food and cooking practices are different. Besides conventionally the nutritional intake of a person is assessed by the food intakeduring the past 24 hours collected by recall or by food diary . Primarily the food itemsconsumed in the previous day were listed out in quantities. Then food items taken duringeach time of the day are converted in terms of raw foods in measurable quantities (likerice ,pulses etc) and then the nutritive value of the raw items are estimated in terms ofcarbohydrate, proteins, fats etc by referring the tables which require an expertise(4,5).No attempt was made to found out a reference nutritive value for the ready made fooditems commonly cooked and eaten by Keralites .In this back ground an attempt was madeto make a simple tool for self assessment of food which can be used by common peopleas well as a guide for therapeutic diet . Methods: Preparation of tool:

The tool was prepared by a team of Doctors from Medical College with adequate expertise and experience in therapeutic nutrition. First a list of commonly consumed cooked and uncooked food items was prepared whichincluded vegetarian and non vegetarian items.Samples of enlisted, commonly cooked food items from 20 house holds belonging todifferent socioeconomic strata were collected. Each item was weighed in electronicbalance and was recorded. . In order to avoid bias during cooking process the persons inthe home who cooked the food were not informed about the procedures. The medianweight of each cooked food item was calculated and used for preparing the referencetable and was expressed in unit of grams. a). Accordingly the weight of cooked food items which can be quantified by counting areas follows: 1 Dosa 20grm, Chappathi20grm, iddily 30grm etc.Corresponding to the weight and bioavailability the nutritive value of the each unit itemwas derived from ICMR food table(1). Dosa Chappathi Puttu Iddilly

20grm 20grm 40grm 30grm

70Cals 70Cals 90cals 90Cals

b).The nutritive value of food items which are measurable are quantified in units of glasses (200 ml) and table spoons (15ml) which are available in

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all our homes. Sambar ¼ glass, Chutney 1 table spoon etc In the ICMR books the measures are available in Katori which is not known to us. Eventhough the rice and curry are served in plates and cups it can be conveniently measured inunits of glasses easily. CookedRice Curd Sambar Parippu

1Glass ½glass 1/2glass ¼ glass

175Cals 50Cals 50Cals 90cals

listwas also include in the tool.The food and energy requirement of a healthy person is based on age, sex, body weightand physical activity requirement of job(1,4,5). Copies of ready made reference table forIndians as prepared by ICMR were available. According to the disease status like obesityand diabetes additions and deletions have to be made. RDA reference table for Indians (ICMR)

Gender

Particular

Body weight

Energy k cal

Protein Fat

Male

Sedentary work Moderate work Heavy work

60kg

2425 2875 3800 50grms 2225 2925

60grms

Female

Sedentary work Moderate work Heavy work

1875 50kg

c) . In the case of locally available uncooked /raw food items like banana, mango the average weight in grams were considered for value calculation. Average weight was estimated from the local market.There nutritive values were available from ICMR books(1,2). According to the nutritive value, the food items are categorized in a fitment table as breakfast, lunch, dinner and snacks according to our food culture. Using the table any personcan prepare a food table for them or assess their own food in take and make choicesaccording to the requirement. For those who require modification the food exchange

20grm

20grms

After the age of 40 to 60 there is 5% reduction of energy requirement of each decade. After the age of 60 there is 10%n energy reduction for each decade. A diabetic require only 90% energy of the normal person. Validation of the tool: The tool was validated in the screening and counseling centreat Medical College Thrissur and was found to be appropriate. The centre had catered as aclinic for nutritional counseling for malnourished children as well as diet therapy for lifestyle disease like diabetes, heart diseases etc. The

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clients found it very user friendly andthe compliance level of nutritional advice was found to be very high . The tool was also used for the following applications. 1. Teaching and learning tool for Nutritional assessment among medical students. 2. Diabetic Patient education cell, Life style clinics. 3. Training of Doctors, Health workers 4. Field level counseling by health workers. This tool for nutritional assessment is simple, self explanatory, user friendly, cost effective and can be used by any common people no health person is required .It is alsorelevant to our food and cultural context. The tool can be used for nutritional education,Health promotion,

Nutritional counseling, Guide for Therapeutic diet. References : 1.Nutrient requirements and recommended dietary allowances for Indians ; Indian Council of Medical research . 2004 2.Gafoorunissa, Kamalakrishnaswamy : Diet and Heart disease. National Institute of Nutrition ,Hyderabad.2004 3.Jayakrishnan T, Jeeja MC ; Disease burden of Kerala :Society for social health action and Research. Kerala. 2006. 4.Park JE ;Text book of preventive and social medicine 19th edition 2009. 5.Mahajan,Gupta;Text book of preventive and social medicine. Jaypee brothers. New Delhi 2005

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Feeding Practices and Nutritional Problems of Infants in Kerala Jeeja M C1 and Jayakrishnan T 2 1 Dept. of Pharmacology, Medical College, Calicut 2 Dept. of Community Medicine, Medical College, Calicut [email protected]

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he Indian state of Kerala with a per capita income of around 1% of that of wealthiest countries has achieved good health comparable to theirs in the past decades. The mostimportant reasons for this achievement were probably the following:High level of femaleliteracy, access to health care, good public distribution system which provides essentialfood items at subsidized rate, political commitment (1,2). Kerala is the first state which isdeclared to implement Baby friendly hospital initiative (BFHI) policy in 100% of thehospitals which means that all hospitals have to follow the practice of exclusive breastfeeding. Ten steps for successful breast feeding included in Baby Friendly Hospital Initiatives (BFHI) by WHO and UNICEF are as follows.(3). 1.

Have a written breast feeding policy communicated to all health staff.

2.

Train all health care staffs in skills to implement policy.

3.

Inform all Pregnant women about the benefits and

management of breast feeding. 4.

Help mothers to initiate breast feeding within half an hour of delivery.

5.

Show mothers how to breast feed and maintain lactation.

6.

No pre lacteal feeding unless indicated.

7.

Practice rooming in and mothers and infants remain together 24 hours a day.

8.

Encourage breast feeding on demand.

9.

Give no artificial teats or pacifiers.

10. Foster the establishment of breast feeding support groups . The Integrated Child Development Service Scheme (ICDS) implemented in India since 1985 include programmes for addressing the nutritional problems of women and children.Under the scheme the anganwadi services (>23000) are available all over the state. Theservices under national nutrition programmes for specific nutritional deficiencies like ironand vitamin A are available even in

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peripheral health centres. To promote good infant feeding practices Government of India have taken legislative measures on prescribing and marketing infant formula(4). The infant milk substitutes feeding bottles and infant foods ( Regulation of Production, Supply and distribution) actwas implemented in India in 1992. The act prohibit the advertisement of the infant milksubstitutes, feeding bottles and infant feeds and incentives for the use or sale of infantmilk substitutes or feeding bottles. No person shall use any health care system for thedisplay of placards or posters for the purpose of promoting those products. Any kind ofinducement or gifts to health workers are prohibited. Violators of this act may be imprisoned for a term which may extend up to 3 years and fine which may extend to Rs5000 or both. Even then the Baby food companies are thriving in the pharmaceuticalmarket and most of them were owned by MNCs.As per the available statistics the current nutritional status of our infants and children arenot much better than the low performing states of north India. This paper will discuss the probable reasons for this condition. Results and discussions. The paper was based on a literature review of the findings of National Family Health Survey III (NFHS III) which was conducted during 2005 06 in all over the country (5). Socio

demographic factors of Kerala : As per the NFHS III reports Kerala is wealthier than the nation as a whole. 45% percent of Keralas households are in the highest wealthquintile. 93 percent of women and 96 percent of men age 1549 are literate in Kerala. Themedian age at first marriage among women of Kerala is 21 years, one of the highest inthe country .At current fertility levels, a woman in Kerala will have an average of 1.9children in her lifetime. All these factors are supposed to be good predictors of childrensnutritional status.The antenatal coverage was almost universal .Almost all births in the last five years tookplace in a health facility (99%), only 1 percent took place at home. Which means that themothers should be adequately equipped to practice exclusive breast feeding. 64% ofbirths took place in a private health facility, compared with 36 percent in a public healthfacility. Feeding practices : Kerala was the first state which was declared to be implemented BFHI in all 100% hospitals which means that all the facilities were following the above 10 practices of BEFI. As per recommendation the new borne should be put on breast immediately withinhalf an hour of birth. 57% started breastfeeding in the first hour of life .and 96% ofchildren were put to the breast in the first day of life , which means that only 4 % of infants are deprived of the highly nutritious first milk (colostrum) . The colostrums

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contain antibodies, nutritive factors and vitamins. It is recommended that nothing be given to children other than breast milk in the first three days when the milk has not begun to flow regularly. However, 11 percent of children are given something other thanbreast milk during that period. It was experienced that some private hospitals werepromoting the habit of pre lacteal feeding using 5% glucose solution (Authors experience). This can predispose to infections and Componentsgrm/ 100grm Proteins Caesin Lactalbumin Aminoacids

malnutrition to the new borne. Although breastfeeding is nearly universal in Kerala, only 56 percent of children under six months of age are exclusively breastfed, as the World Health Organization (WHO) recommends. The rest 64% were given feeding other than breast milk. Most of the timethe breast milk was substituted with cows milk which is not suited to babies(Table 1) .Mothers in Kerala breastfeed for an average of 25 months, one month

Human milk

Cows milk 3.3Too much Too much

Salts Sodium Potassium Chloride

0.9Correct amountsIdeal ratioAdequate for braindevelopment Easily digested and well absorbed. 3.8 Poly unsaturated Needed for brain growth Source of energy 7Aids brain development Lipase present. Helps todigest fats 9meq/litre .correct amount 71311

Minerals mg/100 Calcium Phosphorus Iron Zn

3415 correct amount 0.5 mg/L. Absorption rate 49%4.mg/L

Vitamins Protective substance

Enough

Fats

Sugar Lactose Enzymes Lipase

Bacterial contamination

3.8 More saturated

48 Not adequate Absent Too much increase load on Kidneys. 223529 11792 Too much.leads to tetany 0.5. Absorp tion rate 10%.4mg/L Not enough

Immunoglobulin Leucocytes Bifidus factorLactobacillus bifidus.Lactoferrin Lysozyme Antibodies present None

Likely

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longer than theminimum of 24 months recommended by WHO for most children. The breast feeding counseling should be included as a part of antenatal care .The besttime for breast feeding counseling is during second trimester as one to one or groupwise(4). Various strategies suggested for promoting breast feeding which succeeded in othercountries are formative enquiry, clear consistent messages, target family not just mothers,breast feeding counseling , training for front line workers, peer support , mother tomother support groups and women groups (6). To promote breast feeding .these strategiescan be used in Kerala in future. Specific food supplementation programmes: Specific food supplementation programmes were included in the RCH programme whichare mainly funded by international donors and organizations like WHO and UNICEF. Forprevention of Vitamin A deficiency; centrally sponsored vitamin A prophylaxisprogramme was conducting in all Indian states including Kerala in which massive dosesof Vitamin A in liquid formwere given orally to all children at 6 monthly intervals.Although 78% of lastborn children aged 635 months ate vitamin Arich foods duringthe day or night before the interview, less than half (47%) of children aged 1235 monthswere given a vitamin

A supplement in the past six months. Eating foods rich in iron and taking iron supplements can prevent anemia. Six out of tenlast born children aged 635 months were having ironrich foods during the day or nightbefore the interview, and only 6 percent of children aged 659 months were given ironsupplements in the past 6 months. Through national nutritional anemia control programme all the children below 5 years are given iron tablets which has to be crushedbefore swallowing. Nutritional Status: 25% of children under five are stunted or too short for their age, which indicates that theyhave been undernourished for some time. About 16% are wasted, or too thin for theirheight, which may result from inadequate recent food intake or a recent illness. 23% areunderweight, which takes into account both chronic and acute under nutrition. Even during the first six months of life, when most babies are breastfed, 1416 percent ofchildren are stunted or underweight and 24 percent are wasted. Among children between the ages of 6 and 59 months, 45 percent, are anemic. This includes 24 % who are mildly anemic, 21 % who are moderately anemic, and 1 percentwho suffer from severe anemia. Boys and girls are equally anemic which indicates thatthere is

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with severe anaemia. Mothers and infants form abiological and social unit ; they also share problems of malnutrition and ill health. Interventions done to solve problems of child malnutrition should also address the healthand nutrition of mothers

no gender bias in child rearing or feeding in Kerala. The message that exclusive breastfeeding up to sixmonths and gradual introduction of semislid foods from six months are critical for the prevention of under nutrition in infancy has not been effectively communicated(7). .Onethird of women in Kerala are anaemic, including 26 % with mild anaemia, 7%with moderate anaemia, and 1 %

(6).Sincethe formation of the state in 50s there exist a good public distribution system inKerala through which universally all the people can

Nutritional status of Women and Men Body Mass Index (BMI) Kg/m2

Kerala Women Men

India Women Men

Mean BMI 18.5 to 24.9 (normal) 17.0 18.4 (mildly thin) less than 17.0 (Moderately/ severely thin) 25.0 29.9 (Over weight) 30( Obese)

22.6 53.9

21.6 60.6

20.5 51.8

20.2 56.5

9.6

11.4

19.7

20.4

8.4

10.1

15.8

13.8

23.1 5

15.7 2.1

9.8 2.8

8 1.3

Prevalence of Anaemia inWomen and Men Category Mild Anaemia (10.0 11.9 g/dl) Moderate Anaemia (7 9.9 g/dl) Severe Anaemia (less than 7.0 g/dl) Any Anaemia (less than 12 g/dl)

Kerala Women Men

India Women

Men

25.8

3.8

38.6

13

6.5

3.7

15

9.9

0.5

0.4

1.8

1.3

32.8

8

55.3

24.2

Source NFHS-3-2005-06. MoHFW, Govt. of India .

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get essential food items from the ration shops. This was strengthened by the Kerala rationing order on 1/ 7/1966 and wascontinued by all ruling parties of the state.(8). Now since the implementation of Targetedpublic distribution system ( TPDS) the food subsidy was limited to those having BPLcard holders . Currently of the total 70.32 lakhs ration cards issued in Kerala only 14.9belongs to BPL families who were eligible for food subsidy. The growing nutritional deficiency problems have to be evaluated under the policy of structural adjustedprogrammes (SAP) like TPDS which the country is now under going. According to theNSSO 62cond round survey the monthly percapita consumer expenditure (MPCE) is highin Kerala (Rs 1055.6) compared to that of India total (Rs 624.). Similarly the averageexpenditure on food is high in Kerala . It is Rs 506 in rural and Rs 579 in urbanareas(8).The price elasticity phenomenon may push the people to reduce the expenditureon food items leading them to under nourishment.. Conclusion; Even when 100 % deliveries were occurring in hospitals, 11% had got some pre lactealfeeding. This give a picture of growing consumerism and may be attributed to nexusbetween infant formula marketing companies with private hospitals. Rest 44% of childrenwho have not exclusively breast fed may be fed by breast milk

substitutes or anycommercial formulations. Even with high wealth index the nutritional status of childrenin terms of under weight and anemia are high may be due to false feeding practices due tochanging food culture. Along with urbanization the influence of globalization andchanging of food culture ( macdonaldization) are imbibing the Keralites than any otherstates. In appropriate feeding practices is a major cause for the onset of malnutrition inyoung children. Poor feeding practices are the major threat to their social and economicdevelopment and are among the most serious obstacle to attaining and maintainingoptimal levels of health in this age group(6).The basic under standing that sufficient good quality food will do both save hunger andprevent malnutrition and provide all micronutrients. This fact being undermined in favour of technological fixes to benefit the pharmaceutical and food manufacturing companies.The reach of iron and vitamin A supplementation programmes were also found to be lowpointing that technocratic approach is not a long term strategy for solution of nutritionalproblems. References : 1. Thankappan KR: Some health implications of globalization in Kerala; India. Bulletin of World health Organization 79 (9) 2001.

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2. Aravindan KP, Kunchikannan TP: Changes in Health status of Kerala 1987 1997.

International; family Health survey 200506 India. Mumbai;IIPS: 2007 Sept

Center For Development Studies. Thiruvananthapuram. 2000

6. Vinod paul : Promoting Infant and young child feeding; Health for Millions 2008(4) 1316.

3. Sunder lal. Text book of community medicine CBS Publishers ;New Delhi 2007 152153. 4. Breast feeding Guide lines for doctors: Indian Acdemy of paediatrics Tamilnadu state chapter 5. International institute for population studies and macro

7. Prema Ramachandran; Combating child under nutrition. Health for Millions 2008(4) 39. 8. Economic review Kerala 2008. Kerala state planning borad. Available from http://www.kerla planning board.org. Last accessed on 25/1/ 10.

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