[PDF] Community and Public Health Nutrition

Running head:COMMUNITY AND PUBLIC HEALTH NUTRITION
Question 1
Iron deficiency in India
Background
Iron is an important micronutrient that is essential for the continuation of different
functions of the body (Challa & Amirapu, 2016). It is essential for the differentiation and the
cellular growth, transport, oxygen binding, storage and transport, immune functions, cognitive
function, physical and mental growth (More et al., 2013). Iron deficiency has been a major
public problem in most of the developing countries like India. Iron deficiency occurs when the
body does not have enough mineral iron. Mineral iron can be found in food sources such as red
meat, fish and poultry.
Prevalence

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Iron deficiency is mostly caused in women and children, of whom adolescent girls are the
major victims, however the adolescent boys have also been screened with iron deficiency in
India growth (More et al., 2013). The prevalence of Iron deficiency in India among the
adolescent girls is 68.9 % and that of those within the age 20 -40 years is 69.7 % (Kumari et al.,
2017). The high prevalence of Anemia among the Indians leads to 1.8 % loss of the country’s
Gross domestic product (GDP).As estimated by World Bank, India can face a loss of GDP up to
$20.25 billion in 2017 (Kumari et al., 2017).
Target group
Children, Adolescence boys and girls, pregnant women.
Determinants
The leading cause of Iron deficiency in India is due to the poverty, caste factors and poor
sanitation. A vegetarian diet can also be linked to high iron deficiency. As per the researches,
animal based diet are more absorbable than the plant based diet. The daily Iron requirement for
an adolescent girl is 0.8 mg/1000 Kcal of dietary energy, which is not met in most of the cases
(Challa & Amirapu, 2016). There are several direct determinants for iron deficiency, which can
be due to the insufficient dietary intake or iron absorption, heavy loss of blood due to
menstruation, parasitic infestation and increased demand during the adolescence. In children
over three years and above the family income becomes the factor with its influence over the
hemoglobin level (More et al., 2013).
Impact of health on people with iron deficiency

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Iron deficiency anemia is the leading cause of disability in India. Iron deficiency anemia
reduces the working capacity of an individual and the entire population that can bring about
serious consequences and hurdles to national development according to WHO. According to
Anand et al., (2014), iron deficiency has brought about 17 % of the loss of productivity among
the workers who remain engaged in heavy physical activity. 5 % in those engaged in moderate
physical activities, in India growth (Anand et al., 2014).
It is also responsible for the cognitive deficient caused in malnourished children (Anand
et al., 2014). Since Iron deficiency mostly affects children and women, its impact can be best
understood by looking at the maternal deaths as per the 2014 study published in Nutrition. Iron
deficiency during pregnancy augments the chance of fetal abnormalities, mortalities, preterm and
underweight baby’s growth.
In children, iron deficiency causes impairment of the language skills, motor skills among
the infants and the young children and has been related to a deficit of 5 to 10 points as per the
intelligent quotient. Iron deficiency has also been found to impact the immune system, thus
increasing the chance of inflammatory diseases and infections (Kumari et al., 2017).
Effectiveness of the current and the past approaches
India has adopted the National Nutritional Anemia Prophylaxis Program (NNAPP) since
1970 to fight with anemia ("IFA supplementation - National Nutritional Anemia Prophylaxis
program- India, 2018). Weekly and monthly program of iron and folic acid tablets to the
adolescent girls and the boys were being given from schools. They are screened for moderate to
severe anemia ensuring nutritional assessment and counselling. However as indicated by the

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public health experts, provision of iron tablets to the women are not working as true solutions,
instead It has been found that only 23.7% of the pregnant women have consumed the folate or
the iron tablets provided to them out of those who have received them ("Iron Deficiency Anemia
| National Health Portal Of India", 2018). Most of the women have reported that there are several
side effects of the iron tablets, like vomiting, diarrhea and vomiting, that has attributed towards
the discontinuation of the iron tablets.
Current approaches
The Indian government has allocated $ 5.5 billion to the nutritional schemes, such as
provision of iron rich food in the mid –day meals at schools for the children and the adolescent
girls and boys. During the immunization sessions the health care workers are making sure to
hand over the iron tablets (Anand et al., 2014). Currently the mid- day meal Scheme (MDMS) is
the largest school lunch program in India. This initiative was taken by the Indian government,
not only for controlling the school dropouts but also for providing nutritious food to the school
goers and acted as a supplement for the home meal ("School Education | Government of India,
Ministry of Human Resource Development", 2018).
Some of the other programs that has been launched to control the iron deficiency includes
the Integrated Child Development Services (ICDS) ("ICDS Scheme", 2018); involving the
children suffering from iron deficiency, Matri Suraksha Abhiyan, "Anemia- Chale jao- nischay".
As per the health survey conducted by the department of health, the iron deficiency percentage
has reduced by 12 % in the year 2017, which indicates that the initiatives had been effective but
should be scaled up for getting even more better results.
Data gaps

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It is essential to get an exact record of the hemoglobin status of both the men and women
of the concerned group.
Recommendations
Goal
To decrease the percentage of iron deficiency in India by 50 %, especially in children, adolescent
group and pregnant women by 2020.
Data collection
The national data bases will checked and interviews were conducted with the target group to find
out the gaps related to the health care interventions, such that they can be implemented in the
future practices.
Objective1
By the end of 2018 demonstrate a 40% increase in the iron status of Indian children.
 Strategies
1.1 . The distribution and the consumption of the folic acid tablets by the children should be
monitored.
Provide and monitor The distribution and the consumption of the folic acid tablets by the
children.

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- Evaluation: A group of 100 school going children were taken. 50 of them were kept under
iron rich diet and 50 kept under normal diet. After 2 months the hemoglobin levels will be
measured for evaluating the success.
1.2 Proper nutritional screening can be initiated by the rural health care workers by conducting
free health checkups in schools and the community halls.
- Evaluation: 100 children will be taken and interviews would be conducted to assess their
knowledge regarding iron deficiency within 1 week.
1.3 The mid-day meals provided in the schools should consist of more nutrient rich diets such as,
soya beans, green vegetables, lentils.
- Evaluation: A group of 100 school going children were taken. 50 of them were kept under
iron rich diet and 50 kept under normal diet. After 2 months the hemoglobin levels will be
measured for evaluating the success.
Objective 2
To control the nutrition deficiency anemia in children, adolescents and women in India by 40 %
by the end of 2018
 Strategies
2.1. To conduct individual household survey for the monitoring of the amount of the iron
uptake and the hemoglobin levels in the Indian household. A cheap, durable and reliable
method for the screening of anemia is required.

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- Evaluation: a household survey involving 50 households can be used for monitoring the
daily Indian diets.
2.2. Proper education are provided in schools, hospitals regarding the ill effects of iron
deficiency.
Evaluation- 100 students shall be chosen from the schools and one- on one interviews should
be conducted to understand their nutritional uptake.
2.3. A multi-intervention approach is required that should encompass adequate nutritional
uptake, which involves depending on the food based approach other than the relying on iron
tablets or medical supplementations.
Evaluation- 100 households were selected to monitor the type of food they consume and the
nutritional status of those food should tally with the nutritional standard.

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References
Anand, T., Rahi, M., Sharma, P., & Ingle, G. K. (2014). Issues in prevention of iron deficiency
anemia in India. Nutrition, 30(7), 764-770.
Bhardwaj, A., Kumar, D., Raina, S. K., Bansal, P., Bhushan, S., & Chander, V. (2013). Rapid
assessment for coexistence of vitamin B12 and iron deficiency anemia among adolescent
males and females in northern himalayan state of India. Anemia, 2013.
Challa, S., & Amirapu, P. (2016). Surveillance of Anaemia: Mapping and Grading the High Risk
Territories and Populations. Journal of Clinical and Diagnostic Research : JCDR, 10(6),
LC01–LC06. http://doi.org/10.7860/JCDR/2016/18107.7915
ICDS Scheme. (2018). Retrieved from
http://www.pacsindia.org/projects/health-and-nutrition/icds-scheme
IFA supplementation - National Nutritional Anemia Prophylaxis programme - india - Mother,
Infant and Young Child Nutrition & Malnutrition - Feeding practices including
micronutrient deficiencies prevention, control of wasting, stunting and underweight.
(2018). Retrieved from http://motherchildnutrition.org/india/vitamin-a-ifa-
supplementation.html
Iron Deficiency Anemia | National Health Portal of India. (2018). Retrieved from
https://www.nhp.gov.in/disease/blood-lymphatic/iron-deficiency-anemia

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Kumari, R., Bharti, R. K., Singh, K., Sinha, A., Kumar, S., Saran, A., & Kumar, U. (2017).
Prevalence of Iron Deficiency and Iron Deficiency Anaemia in Adolescent Girls in a
Tertiary Care Hospital. Journal of Clinical and Diagnostic Research : JCDR, 11(8),
BC04–BC06. http://doi.org/10.7860/JCDR/2017/26163.10325
More, S., Shivkumar, V. B., Gangane, N., & Shende, S. (2013). Effects of iron deficiency on
cognitive function in school going adolescent females in rural area of central India.
Anemia, 2013.
School Education | Government of India, Ministry of Human Resource Development. (2018).
Retrieved from http://mhrd.gov.in/mid-day-meal

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Question 4
Outline of the issue
Food security can be defined as the condition related to the availability of food resources.
It is a flexible concept and has been reflected in the many attempts in research and the use of the
policies (Tscharntke et al., 2014). It is a concept that has arisen due to the international food
problem at the time of the global crisis. The initial focus was on the problem related to the food
supply or due to the instability of the food prices at the national and the international level (Elliot
et al., 2013). Studies of the indigenous people of Australia repeatedly demonstrate their
vulnerability to household food insecurity and they are subjected to face a number of socio-
demographic factor linked with the food insecurity (extreme poverty, living in the rental
accommodation, dependence on the social assistance) (Tscharntke et al., 2014). Practitioners and
researchers have highlighted some of the distinct food procurements, preparation and the
distribution practice among the aboriginal of Australia (Tscharntke et al., 2014). The measure of
the household food insecurity can be related to the food procurement from both the market and
the traditional sources. Other broader factors include the environmental factors such impact of
the climate change and environmental pollution on the edible plants and animals available in
nature (Fiddler, 2012).
Prevalence
Food security issues faced by the aboriginals and the Torres Strait Islander vary across
the nation. As per the National Aboriginal and Torres Strait Islander survey, 30% of the
aboriginals have been found to be going without food occasionally, indicating towards intensive

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food insecurity (Shindell et al., 2014). The aboriginal Australians living in the remote areas are
likely to have run out without food (36%) compared to the ones those living in the non-remote
areas. Food insecurity among the aboriginals have been found to be higher among the aboriginals
with prolonged hunger, anxiety about getting the food and relying on the food relief (Fiddler,
2012). In 2008, it has been found that 55 % of the surveyed communities cannot get access to
fresh food due to weather or the road conditions and one third of the households reported days
without food due to lack of money (Wheeler & Von Braun, 2013). As per the Victorian
population health survey 51% of the parents and the carers have reported running out of stock
and not being able to buy food due to financial crisis (Fiddler, 2012).
Determinants of food security
Socio-economic capacity, food accessibility, food use, limited food resources and
infrastructure determines the food security. Employment status, home ownership, education level
and housing cost also plays a crucial role in food insecurity, especially for the workers who get
low wages. According to Shindell et al., (2014), aboriginals are subjected to food insecurity due
to inadequate incomes or poverty and welfare dependency. As per the reports the aboriginal
people were min the lowest quintile of the equivalent gross weekly household in compared to 20
% of the non-indigenous Australians (Rhea, 2012). It has been estimated that welfare dependent
families in the urban areas have to spend about 40% of their disposable income in the healthy
food, whereas in the remote communities they have to spend 50 % if their disposable income
(Pollard, 2013). Access to the proper transport and food stores are some of the important
determinants of food security (Markwick et al., 2014). Furthermore the variety and the quality of
the food found in the remote communities are energy dense and are deprived of the nutrients
such as deep dried food and sweetened drinks (Markwick et al., 2014). Food costs have risen

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drastically that have affected the food pricing in the remote areas. Research consistency has
found that healthy food baskets costs about 20 -40 % more in the remote areas compared to that
in the major cities, due to the store management prices, freight charges and the lessened
economies of scale for purchasing and retailing in remote communities cater to high prices
(Fiddler, 2012). It has been found that the mean income level decreases with the remoteness,
yet arise in the food costs is found in the remote areas inhabited by the aboriginal people
(Pollard, 2013). The health infrastructure also plays a major role in food security (Rhea, 2012).
The overcrowding in the dwelling place, lack space for food storage, preparation and cooking
can be an important determinant. In the aboriginal communities in Australia about 6 % of the
houses have proper nutritional hardware. Nutritional education related to shopping, choosing
healthy food and budgeting also affects food security.
Previous strategies and Current strategies
There had been numerous calls related to the strategies for achieving equity in the
availability of the food products by the National nutrition network conference and close the gap
National Indigenous Health Equality Summit, the enquiry in to the remote stores and the national
2020 summit (Close the gap, 2015).
The Australian health survey has been collecting information about the aboriginal health
such as self-reported diet, physical activity and smoking, measurement of the chronic diseases,
like blood pressure, obesity, cholesterol levels and indicators of the nutritional status like the
Vitamin D levels and iron deficiency (RACGP, 2016). The coordinator general for the remote
indigenous survey act was established, which involved the provision of a coordinator for the
remote Indigenous service who would monitor, advice and assess the initiative taken for

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progressing towards closing the gap targets .The remote indigenous service act of 2009 requires
a close monitoring and assessment (RACGP, 2016).
Recommendations
In order to support a food security response for the aboriginal people are adequately
resourced and appropriately an excellent cross cultural competency and communication are
important for developing a proper workforce in this area. Nutritional education can be provided
as strategy for improving the diet and the food choices (Davy, 2016). A well supported educated
and resourced aboriginal and Torres Strait Islander nutrition workforce is required for providing
appropriate interventions to the vulnerable group of people. It also necessary to expand the
funding for the aboriginal people. Furthermore, it is necessary to map actions for food security
that helps one to understand the indicators of food insecurity (Davy, 2016). A national, strategic
coordinated and cross sectoral approaches are required for addressing the food security. Local
government should facilitate local solutions for improving the supply and the access to nutritious
food. Taxations and food subsidies should be considered for the aboriginals.

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References
Close the gap, (2015). Indigenous health equality. Retrieved from:
https://www.humanrights.gov.au/publications/closing-gap-national-indigenous-health-
equality-targets-2008.
Davy, D. (2016). Australia’s Efforts to Improve Food Security for Aboriginal and Torres Strait
Islander Peoples. Health and Human Rights, 18(2), 209–218.
Elliott, B., Jayatilaka, D., Brown, C., Varley, L., & Corbett, K. K. (2012). “We are not being
heard”: Aboriginal perspectives on traditional foods access and food security. Journal of
environmental and public health, 2012.
Fiddler, T. (2012). Food security in a northern First Nations community: an exploratory study on
food availability and accessibility. International Journal of Indigenous Health, 8(2), 5.
Markwick, A., Ansari, Z., Sullivan, M., & McNeil, J. (2014). Social determinants and lifestyle
risk factors only partially explain the higher prevalence of food insecurity among
Aboriginal and Torres Strait Islanders in the Australian state of Victoria: a cross-sectional
study. BMC public health, 14(1), 598.
Pollard, C. (2013). Selecting interventions for food security in remote Indigenous communities.
In Food Security in Australia (pp. 97-112). Springer, Boston, MA.
RACGP, (2016). Food security and nutrition in Aboriginal and Torres Strait Islander
communities. Retrieved from: https://www.racgp.org.au/newsGP/Racgp/Food-security-
and-nutrition-in-Aboriginal-and-Torrait strait Islander

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Rhea, Z. M. (2012). Knowing country, knowing food: Food security and Aboriginal-settler
relations in Victoria. Artefact: the Journal of the Archaeological and Anthropological
Society of Victoria, The, 35, 17.
Shindell, D., Kuylenstierna, J. C., Vignati, E., van Dingenen, R., Amann, M., Klimont, Z., ... &
Schwartz, J. (2012). Simultaneously mitigating near-term climate change and improving
human health and food security. Science, 335(6065), 183-189.
Tscharntke, T., Clough, Y., Wanger, T. C., Jackson, L., Motzke, I., Perfecto, I., ... & Whitbread,
A. (2012). Global food security, biodiversity conservation and the future of agricultural
intensification. Biological conservation, 151(1), 53-59.
Wheeler, T., & Von Braun, J. (2013). Climate change impacts on global food security. Science,
341(6145), 508-513.