General Health Indicators

• IMR – 11.2 per 1,000 live births (Register General’s Dept.)

• MMR – 39.3 per 100,000 live births (FHB. 2006)

• TFR (Total fertility rate) - 2.4 per woman (DHS. 2006/7)

• GFR (General fertility rate) - 79.0 per 1,000 women (DHS. 2006/7)

• CBR - 18.7 per 1,000 population (DHS. 2006/7)

Improvement over the time

1945 2000

CBR/1000 Population a 36.6 17.6

CDR/1000 Population a 21.9 5.6

MMR/1,000 Live Births a 165.2 2.0

IMR/1,000 Live Births a 140.0 13.6

Life Expectancy at Birth (Yrs) b

Male

Female

43.9

41.6

72.0

76.0

Literacy Rate b Male

Female

70.1

57.8

92.5

90.1

a / Vital Statistics, Dept. of census & Statistics

b/ Central Bank Annual Reports

Nutritional Indicators

• LWB 16.6% (DHS. 2006/7)

• Average weight gain in pregnancy 8kg

(FHB MIS, MRI survey report 2003)

• Under 5 yr children (DHS. 2006/7)

– Stunting 18.0%– Wasting 15.0%– Underweight 21.6%

Nutritional Indicators

• Nutritional status of women

(15-49 yrs)– Undernourished (BMI<18.5) -

21.8%– Overweight (BMI >25.0) -

24.0% (DHS. 2000)

• Over nutrition– Adolescents 6.0%– Non pregnant women 19.9%

Thinness

Normal Over weigh

t

Obese

Urban 15.2 % 49.1 % 26.3 % 9.3 %

Rural 25.3 % 55.7 % 16.1 % 3.0 %

Estate 40.4 % 56.1 % 2.6 % 0.9 %

Latest data – DHS 2006/7

Trends in LBW

23

20.519.9

17.9 17.8

16.416.7

16.1

17.1 16.9 17.117.6

16.6

15

16

17

18

19

20

21

22

23

24

25

1988 1994 1995 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006

LBW percent

Medical Statistician and DHS surveys 1993,2000,2006

Urban 11.6%

Rural 17.0%

Estate 20.8% (DHS. 2000)

(DHS. 2000)

57.3

54.3

43

38.1 37.7

30.729.4

49.9

44.6

36.2

27.5

23.8

16.1

13.513.9 13.9

11.612.9

15.5

12.814

22.821.6

18.4 18

15.5 15

10

15

20

25

30

35

40

45

50

55

60

1975-76 1977-78 1980-82 1987 1993 1995-96 2000 2006-07

year

perc

entag

e belo

w -2S

DTrends in Nutritional Status of <5 years

- Underweight

- Stunting

- Wasting

Department of Census and Statistics, DHS 1987,1993,2000, 2006/7

Protein Energy Malnutrition

Causes

Inadequate & faulty diets

Poverty

Socio-economic factors

Environmental factors

infections

PEM - MACRONUTRIENT DEFICIENCY

Often associated with

INFECTIONS

Micronutrient deficiencies

Sanitation

personal hygiene

infection

malnutrition

Host diet environment

Eg :-

Young child - Energy needs

Protein needs

Staple diets Energy density

Protein content

Feeding frequency

Inadequate food availability

Poverty Inequity Lack of land

Infections Anorexia

Food intake

Absorption

Utilization

losses

Famines

Droughts, Natural disasters, War, Civil disturbances

Inappropriate weaning practices

Malnutrition

Marasmus Kwashiorkor

Marasmic Kwashiorkor

Emaciated Bilat pitting oedema

Legs trunk moon face

Fat & muscle Fat & muscle

Prominance of Scapulae Spina & Ribs

Skin lesion & Atrophy, erythema, desquamation

Old man’s appearance

(Thin flaccid skin)Pale

Normal hairHair changes (yellow, red, sparse, bald patches)

Frequent infections

with signsFrequent infections

imbalance

Asso. with dehydration

Dehydration

Alert & irritableLethargic, miserable irritable

E

NON CLINICAL FORMS WASTING - (wgt / hgt)

STUNTING - (hgt / Age)

UNDERWEIGHT - (wgt / Age)

Changes in internal organs Gastrointestinal tract

- Mouth, Tongue, Throat

Atrophic mucosa / ulceration

Gums infected

salivary glands – atrophy

acute parotitis / oesophageal ulcers

- Mucosa of GI tract

Atrophy / Absorption

- Muscle tone in intestinal muscles

Rectal prolapse

Liver

- Fatty change

Pancreas

- Extreme wasting

Kidneys

- size

- infections

Endocrine system - Pituitary gland

- Adrenal gland

- Thyroid

- Thymolymphatic system

Haemopoietic system

- Anaemia ~ Protein

~ Iron

~ Folic Acid

- Chronic infection

~ suppressed BM

Muscles

- Wasting

Heart

- General Atrophy

- Cardiomegaly in Anaemic patients

Skin changes

Bone

Dental development

CNS

29.9

20.9 22.3

31.6 30.3

0

5

10

15

20

25

30

35

Percen

tage (%

)

Pre schoolchildren

School children Adolescent Non pregnantwomen

Pregnant women

Anaemia Status of Sri Lanka,MRI,2001

Prevalence of Anaemia in Different groups

in Sri Lanka

27.3

30.6 31.2

25

32.8

40.1

28

0

5

10

15

20

25

30

35

40

45

Perc

entag

e

Wes

tern

Sout

hern

Cent

ral

Saba

raga

muw

a Uva

North

Cen

tral

Way

amba

Distribution of Anaemia in Pre-school

children (6-59 months)

by province

Anaemia Status of Sri Lanka,MRI,2001

Trends in the prevalence of iron

deficiency anemia among

under five children

70

45

29.9

0

10

20

30

40

50

60

70

80

1973 1996 2001

Anemia

Iron Deficiency

Amount of Iron in the body

3 – 4 gm

> 50 % of it Hb

Rest muscle (myoglobin)

liver

Hb O2 metabolic activities

cells

Daily requirement

14 mg / day

12 mg / day

Haem Non haemAbsorption 40 %

Fish, meat, dry fish

(Enhancing factors

Vit C,sour things)

10 – 15 %

Cereals, pulses, vegetables, fruits, eggs, dairy

(Inhibiting factors

Tannin, caffain)

Iron storage

Compounds - Ferritin

- Hemosiderin

Iron affects :-- Cognitive development

- Concentration

- Attentionspan

- Memory

- Learning

- Physical growth

- Muscle function

- Immunity to disease & illness

- Social interaction

Life cycle

- New born

- Infant

- Preschooler

- Primary schools

- Adolescents

- Adults

- Elderly

Liver

RES

BM

preg:

lact:

normal

Strategy for the Control of Anaemia

Dietary diversification, Nutrition education & local

food sources

EBF + Complementary feeding

6/12 BF – 2 years

Modify diets adding local nutrient rich

Avoid Tea with meals

Enhancing / Inhibiting factors

Horticultural projects

Livestock programmes

Ensue access to varied food supply to

obtain adequate diet, school garden

Nutrition Education

All institutional diets according to

nutritional requirements

Supplementation

Fe supplementation

Targets

Infants E BW

Preschoolers

Primary school children

Weekly supplementation

of child bearing age group

Blanket coverage to displaced & refugee camps

Fortification

Vitamin A deficiency

• Prevalence of Vitamin A deficiency (serum retinol levels less than 20µg per dl)

Among 6-71 months

1996 35.3% a

2005 29.3% b

a/ Vit A Deficiency status of children in Sri Lanka 1995/1996. MRI. 1998

b/ MRI. 2005 (unpublished data)

Vitamin A deficiency

Public Health Problems

▲ Blindness

▲ Duration of morbidity

▲ Mortality

asso. with other Nutritional disorders

(infections PEM)

Causal factors ~ Host

~ Diet

~ Environment

Host : Age younger age

(infants / preschool)

Growth

intake of milk, greens

Diet : intake of greens & fat

animal protein

Environment :

Seasonal food availability

Infections , Infestations

Socio Economic

Needs :- (Functions)

o Synthesis of photosensitive pigment of Retinal cells

o Cell differentiation of Epithelium

o Normal growth

o Reproduction

o Immune competance

Dry skin :-Follicular keratosis

Sweet / sebaceous gland blocked by keratin plugs

Secretions

Dry skin

Storage :-

95 % in Hepatic cells

Hepatocytes secrete “ Retinol Binding Proteins”

DIAGNOSIS :-

Clinical features Night blindness

Conjunctival xerosis

Corneal cerosis

Conj. Xerosis with ulceration

Keratomalacia

Corneal scars

Biochemical Tests

- S. Retinol level

- Relative dose response

Dietary assessments

- Hellen kellar food frequency

Conjunctival Impression Cytology

Liver biopsy / necropsy

Vitamin A Policy

Recommendations & (Px & control)

Dietary modifications

1. Ensue food security

● Promote home gardening

● Food & agriculture policies

(multi sectoral approach)

● Research to crops with micronutrients

● Proper storage to nutrient losses

● Food preservation

2. Information , Education & Communication (IEC) BCC

3. Promote BF / CF

Fortification Commercially , local production

SLS certificate for forti. Food

Supplementation

- pregnant mothers

- Regular supply of Thriposha

Vitamin A mega dose Regime

Post Partum :

200,000 I u within 4 wks after delivery

Child 0 – 59 months

> 9 months

> 18 months

> 36 months

School children

grade 1, 4, 7 :- 100,000 I u

Special situations ~ Displaced

~ Estate

~ Garment factory workers

~ Prisoners

~ Orphans

100,000

promote dietary modification

100,000 I u

Iodine Deficiency Disorders

• Total goiter rate in children aged 6-9 years

2000/2001a 20.1%2005b 3.8%

Central 10.3%

Uva 7.8%

Western 7.3%

a/ Case studies on successful micronutrient prorammes: The Sri Lankan experienceb/ Iodine nutrition status in Sri Lanka 2005. MRI . 2006

IODINE DEFICIENCY DISORDERS

Sole function of iodine - participation in the synthesis of

THYROID HORMONES (T4 + T3)

THYROID HORMONES – VITAL FOR PHYSICAL

& MENTAL

DEVELOPMENT

Severity of mental / physical retardation depend

on the severity of iodine deficiency

SPECTRUM OF IODINE DEFICIENCY• Cretin or deaf mute

• Mental & physical growth retardation

• Goitre

• Delayed menarche

• Amenorrhoea

Endemic goitre

• A significant proportion of the popluation has

palpable or obviously enlarged thyroids

Indicators• Goitre prevelance

• Urine iodine levels

• Iodine levels of salt

Interventions on Food & NutritionPolicies, Strategies &

Programmes

1. Antenatal care & supplementation

2. Promotion of breast feeding (BF code & Baby friendly hospitals & maternity leave)

3. Growth monitoring & promotion

4. Complementary feeding

5. Thriposha supplementation

Interventions on Food & Nutrition

6. Vitamin A mega-dose

7. Food subsidy -“Poshana Malla”, “Kiri weeduruwa”

8. School health programmes – exercise programme, canteen policy, etc

9. School feeding programmes

10. Special food subsidy for IDPs, Plantation workers

Cont…

11. Health & Nutrition promotion - Education programmes for pregnant & lactating women, school children

12. Hospital diet modification

13. Food fortification – salt iodization

14. Nutrition in emergencies

Interventions on Food & Nutrition

Cont…

• Poorly coordinated

• Poorly targeted - Thriposha programme

• Inadequate rational & irregular supply- Thriposha programme

• Poor attention on vulnerable areas & groups – Estates

Weaknesses

Weaknesses

• Inadequate coverage of services – some estate areas

• Over burdened at grass root level health workers

• Inadequate training & poor dissemination of current knowledge to grass root level

• Inadequate supervision & monitoring…Quality

Cont…

Suggestions

• National inter sectoral committees (chaired by Hon PM/ Hon ministers)

• Establishment of NSC (chaired by SH&N)

• Strengthening intra & inter sectoral coordination at all level

• Provincial/ District nutrition committees

• National nutrition policy

• National strategic plan/ annual action plans – National, District & Divisional

Suggestions

• Improve targeting effort (mapping out vulnerable areas & groups)

• Strengthening existing progrmmes – BCC, re-targeting, area specific programmes with triple A approach

• Due consideration gives to new initiatives -DFS, micro nutrient supplementations

• Encouraging dounor assisstance

• Increase capacity of thriposha factory & ensure regular supply

Cont…